Quick Overview
Seniority
Mid Senior
Work mode
On Site
Location
Coppell, TX, United States
Posted
23 hours ago
COBRACRMComplianceHIPAAPharmacyProcess ImprovementReconciliationRegulatory Compliance
Job Description
Job Title: Operations Manager – Healthcare Payer Operations
Location: Onsite Coppell, Texas(5 days/week in office)
Duration: Fulltime/contract
Job Summary
Seeking an experienced Operations Manager to oversee daily healthcare operations within a payer environment.
The ideal candidate will have experience managing claims, eligibility, enrollment, billing, member services, provider operations, client support, vendor performance, and operational reporting. Experience supporting Medicare health plans is preferred.
Knowledge of self-funded health plans, Third-Party Administrator operations, stop-loss insurance, or Pharmacy Benefit Managers is beneficial but not required.
Key Responsibilities
Manage day-to-day healthcare payer operations.
Oversee claims, eligibility, enrollment, billing, reconciliation, and member-service activities.
Monitor operational performance, service levels, accuracy, turnaround times, and client response times.
Manage escalations involving claims, members, providers, employer groups, clients, or vendors.
Develop and improve workflows, standard operating procedures, controls, and escalation processes.
Prepare operational reports, dashboards, trend analyses, and leadership updates.
Coordinate with internal teams, provider networks, technology partners, PBMs, utilization-management vendors, and other healthcare partners.
Support client implementations, plan transitions, system migrations, and vendor changes.
Ensure compliance with HIPAA, CMS requirements, ACA, COBRA, and other applicable healthcare regulations.
Hire, train, mentor, and manage healthcare operations team members.
Promote accountability, service quality, process improvement, and cross-functional collaboration.
Required Qualifications
Five or more years of healthcare operations experience within a health plan, managed-care organization, payer, benefits administrator, or similar environment.
Strong understanding of claims, eligibility, enrollment, billing, member services, and healthcare operational workflows.
Experience managing operational teams, vendors, service levels, escalations, and performance metrics.
Knowledge of healthcare regulations and compliance requirements.
Strong communication, leadership, analytical, organizational, and problem-solving skills.
Ability to manage multiple priorities in a fast-paced environment.
Must be able to work onsite daily in Coppell, Texas.
Preferred Qualifications
Experience supporting Medicare Advantage, Medicare Supplement, Medicare Part D, or other Medicare plans.
Experience working with CMS requirements and Medicare operational processes.
Experience with self-funded health plans, TPA operations, stop-loss insurance, or reinsurance.
Experience working with Pharmacy Benefit Managers.
Knowledge of utilization management, care management, provider networks, and healthcare cost-containment programs.
Experience implementing or migrating claims-administration platforms.
Familiarity with claims systems, CRM platforms, reporting tools, and healthcare data exchanges.
Core Competencies
Healthcare Payer Operations
Medicare Plan Operations
Claims and Eligibility Management
Member and Provider Services
Operational Reporting and KPIs
Vendor and SLA Management
Regulatory Compliance
Process Improvement
Team Leadership
Cross-Functional Collaboration
The ideal candidate will have experience managing claims, eligibility, enrollment, billing, member services, provider operations, client support, vendor performance, and operational reporting. Experience supporting Medicare health plans is preferred.
Knowledge of self-funded health plans, Third-Party Administrator operations, stop-loss insurance, or Pharmacy Benefit Managers is beneficial but not required.
Key Responsibilities
Manage day-to-day healthcare payer operations.
Oversee claims, eligibility, enrollment, billing, reconciliation, and member-service activities.
Monitor operational performance, service levels, accuracy, turnaround times, and client response times.
Manage escalations involving claims, members, providers, employer groups, clients, or vendors.
Develop and improve workflows, standard operating procedures, controls, and escalation processes.
Prepare operational reports, dashboards, trend analyses, and leadership updates.
Coordinate with internal teams, provider networks, technology partners, PBMs, utilization-management vendors, and other healthcare partners.
Support client implementations, plan transitions, system migrations, and vendor changes.
Ensure compliance with HIPAA, CMS requirements, ACA, COBRA, and other applicable healthcare regulations.
Hire, train, mentor, and manage healthcare operations team members.
Promote accountability, service quality, process improvement, and cross-functional collaboration.
Required Qualifications
Five or more years of healthcare operations experience within a health plan, managed-care organization, payer, benefits administrator, or similar environment.
Strong understanding of claims, eligibility, enrollment, billing, member services, and healthcare operational workflows.
Experience managing operational teams, vendors, service levels, escalations, and performance metrics.
Knowledge of healthcare regulations and compliance requirements.
Strong communication, leadership, analytical, organizational, and problem-solving skills.
Ability to manage multiple priorities in a fast-paced environment.
Must be able to work onsite daily in Coppell, Texas.
Preferred Qualifications
Experience supporting Medicare Advantage, Medicare Supplement, Medicare Part D, or other Medicare plans.
Experience working with CMS requirements and Medicare operational processes.
Experience with self-funded health plans, TPA operations, stop-loss insurance, or reinsurance.
Experience working with Pharmacy Benefit Managers.
Knowledge of utilization management, care management, provider networks, and healthcare cost-containment programs.
Experience implementing or migrating claims-administration platforms.
Familiarity with claims systems, CRM platforms, reporting tools, and healthcare data exchanges.
Core Competencies
Healthcare Payer Operations
Medicare Plan Operations
Claims and Eligibility Management
Member and Provider Services
Operational Reporting and KPIs
Vendor and SLA Management
Regulatory Compliance
Process Improvement
Team Leadership
Cross-Functional Collaboration
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