Manager - Health Plan Operations

Overview

Our client is seeking a Health Plan Operations Leader to oversee key functions such as TPA/BPO management, claims, utilization management, and pharmacy services. This role requires strong leadership skills and knowledge of Medicare and Medicaid regulations. The successful candidate will play a vital role in transforming how older adults receive care, allowing them to age comfortably at home and in their communities. Key Responsibilities ● Lead Health Plan Operations ensuring staff are trained and equipped to deliver on organizational goals ● Manage vendor oversight for key vendors such as TPA/BPO, PBM, and pharmacy services ● Oversee all Medicare Part D operations including reporting, compliance, and audits ● Develop processes to maintain participant Medicaid & Medicare eligibility ● Collaborate across departments to support authorizations, billing, claims, and appeals processes ● Lead collaboration and education across all teams to enhance understanding of Health Plan services ● Manage enrollment and dis-enrollment activities ensuring compliance with regulatory requirements ● Oversee enrollment data management and data systems coordinating with vendors to meet program requirements ● Manage workflows related to self-pay and private billing processes in collaboration with accounting and TPA/BPO ● Collaborate with analytics teams to monitor claims processing, enrollment reconciliation, and Part D activities ● Lead operations by providing care teams with tools and processes for efficient decision-making ● Assist with government relations activities and collaborate on regulatory audits such as CMS and State reporting ● Support reinsurance activities and collaborate with the Finance team on key reporting requirements ● Oversee access to online systems and portals ensuring Health Plan Operations are compliant and data is secure ● Continuously seek improvements to processes and systems as the organization grows and increases in complexity ● Build, mentor, and manage teams supporting various Health Plan Operation functions ● Communicate confidently and persuasively with internal and external stakeholders to ensure clarity and transparency ● Embrace additional opportunities and responsibilities as needed actively participating in the continued growth and success of the organization Schedule and Shift Details ● Monday - Friday, 8a-5p. Hybrid role supporting Greater Los Angeles and South Los Angeles Markets Travel ● Up to 40% travel required Benefits: ● 401k with Employer match ● Your choice of 6 medical plans, with premium coverage of up to 80% for employees and 75% for all dependents ● Dental, vision, health savings account, flexible spending accounts, short- and long-term disability coverages ● PTO starting at 20 days per year; plus 12 paid holidays per year, and 2 floating holidays per year ● Generous CME/CEU budget and time off, and professional development opportunities ● One-time stipend towards setting up your home office (for remote or hybrid roles) ● Family friendly policies, including paid new parent leave!

Qualifications

• Bachelor's degree or higher
• 4+ years of experience in ALL of the following:
  • Health Plan Operations
  • Medicare D Operations
  • TPA/BPO management
• 3+ years of experience in ALL of the following:
  • Vendor Management
  • Data and Systems Management
  • Utilization Management
  • Enrollment Oversight
• Have you applied at Myplace Health within the last 90 days?
• Have you spoken to a recruiter via phone regarding this role?

• PACE (1+ years)

Benefits

Company

Our client was founded in 2021 by mission-aligned healthcare leaders and organizations that are committed to drastically improving health outcomes, quality and experience for vulnerable older adults and frail seniors. We are a multidisciplinary team of clinicians, operators, technologists, entrepreneurs, and builders who are united around our mission and seek meaningful careers that improve the lives of some of the most vulnerable members of our community.