Supervisor, Health Plan Claims Operations

Supervisor, Health Plan Operations

At Harbor Health, we are enhancing healthcare in Austin through strategic collaboration and innovative practices. We are looking for individuals to help us develop a member-focused experience that integrates comprehensive care with a modern payment model. The Supervisor, Health Plan Operations, plays a critical role at Harbor Health by ensuring accuracy, integrity, and compliance with TDI rules and regulations. This position is responsible for claims quality and timeliness of payment while improving claims processing efficiency and accuracy, reducing operational costs, and improving member satisfaction. They oversee TPA business partner operations, ensuring TPA attains SLAs, manage the operation budgets, ensure quality for responsible teams, and monitor compliance with regulatory bodies. The position supports Harbor Health's mission by directly impacting the support of member satisfaction and health through timely and accurately processing healthcare transactions such as claims and supporting transactions.

Position Duties & Responsibilities

Support service and product expansions : Assist in the operational aspects of service area and product expansions. Work closely with strategic planning and development teams to integrate new providers and services into the network.

Inspect and review the quality of claims processing with providing feedback to TPA as appropriate.

Review and approval of Cost Share claims between Harbor and TPA.

Produce a monthly report on accuracy of Harbor's Cost Share selection logic.

Proactively find opportunities to improve operational efficiency, member experiences and processes providing feedback to internal partners.

Oversee TPA and their product partners to ensure the quality delivery of services.

Building conditions for success removes obstacles, leads, and champions change.

Responsible for ongoing monitoring of work to ensure consistent execution of processes and adherence to guidelines and frameworks.

Manage issues and make appropriate decisions based on the policy.

Facilitate and guide employees through skill identification and developing for career progression Supports projects by serving as a subject matter expert.

Consistently coach employees on claims handling and find opportunities to improve overall process and engagement.

Ensure risks associated with business activities are effectively identified, measured, supervised, and controlled in accordance with risk and compliance policies and procedures.

Achieve monthly SLAs and address any misses with the TPA to resolve issues. This includes the TPA partner and their associated companies.

Approve claim payment runs for release to production.

Required Professional Skills & Experience

Bachelor's degree or 6+ years of relative health care operation experience in ACA.

Four years' experience managing health care Operation teams that include claims, members, member / group billing, and provider domains.

Strong knowledge of ACA / IFP and commercial claim requirements, rules, and regulations. Problem-solving and managing multiple priorities.

Previous team building and development experience.

Detail-oriented, initiative-taking, and capable of working independently as well as part of a team.

Prior work in implementing new insurance products by working with the TPA in bringing to production.

Experience in oversight management of the TPA operations of claims.

Background in developing and reviewing operation SOPs and business requirement documents.

Strong written and verbal communication skills with the ability to know when each is appropriate.

Prior experience in developing RFIs.

Preferred Professional Skills & Experience

Familiarity with Texas Department of Insurance (TDI) rules, regulations, and law.

Experience in the Start Up phase of a health plan.

Background in building Operations teams that include members, claims, and provider domains.

Advanced knowledge of state and federal health care regulations, especially pertaining to network management and provider relations.

Strong Excel and Power Point background.

Experience in building and managing budgets.

Elevated level of integrity and reliability, with a commitment to maintaining confidentiality and adherence to compliance standards.

What We Offer

Opportunity to shape, develop and mentor individuals to grow their career and impact their lives.

Collaborative and dynamic work environment.

An organization made up of people who are passionate about changing the healthcare landscape.

Competitive salary and benefits package.

Professional development and growth opportunities.

A transparent and unique culture.