Manager-Health Plan Operations - Valere Staffing

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

required

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