Manager/Senior Manager, Health Plan Operations - myPlace Health

What does success look like?

• Lead Health Plan Operations: Ensure staff are trained and equipped to deliver on organizational goals and maintain operational excellence.
• Vendor Oversight: Manage and provide oversight for key vendors such as TPA/BPO, PBM, and pharmacy services to ensure effective service delivery.
• Medicare Part D Leadership: Oversee all Medicare Part D operations, including reporting, compliance, and audits.
• Eligibility Management: Develop processes to maintain participant Medicaid & Medicare eligibility, resolve issues, and ensure timely data monitoring.
• Collaborate Across Departments: Work with Finance and Care Delivery operations to support authorizations, billing, claims, and appeals processes.
• Cross-Disciplinary Education: Lead collaboration and education across all teams to enhance understanding of Health Plan services.
• Enrollment Oversight: Manage enrollment and disenrollment activities, ensuring compliance with regulatory requirements, and provide continuous training.
• Data and Systems Management: Oversee enrollment data management and data systems, coordinating with vendors to meet program requirements.
• Billing Support: Manage workflows related to self-pay and private billing processes in collaboration with accounting and TPA/BPO.
• Claims and Reconciliation Monitoring: Collaborate with analytics teams to monitor claims processing, enrollment reconciliation, and Part D activities.
• Utilization Management: Lead operations by providing care teams with tools and processes for efficient decision-making.
• Support Regulatory Audits: Assist with government relations activities and collaborate on regulatory audits, such as CMS and State reporting.
• Reinsurance and Finance Collaboration: Support reinsurance activities and collaborate with the Finance team on key reporting requirements.
• Access and System Oversight: Oversee access to online systems and portals, ensuring Health Plan Operations are compliant and data is secure.
• Process Improvement: Continuously seek improvements to processes and systems as the organization grows and increases in complexity.
• Team Building and Mentorship: Build, mentor, and manage teams supporting various Health Plan Operation functions.
• Effective Communication: Communicate confidently and persuasively with internal and external stakeholders to ensure clarity and transparency.
• Contribute to Organizational Growth: Embrace additional opportunities and responsibilities as needed, actively participating in the continued growth and success of the organization.

Additional Information

• This role will be a hybrid role supporting both our Greater Los Angeles and South Los Angeles Markets. This position will require up to 40% of the time in markets as needed to support business needs
• Schedule is Monday - Friday
• This position falls under the FLSA Exempt status.

PI251048338