Health Plan Operations Manager - Remote ($150K)

Confidential Careers; Orlando (FL); Remote; USD 150,000; Full time

Job summary

A leading company seeks a Health Plan Operations Manager to oversee health plan operations, ensuring regulatory compliance and operational efficiency. The role involves managing audits, stakeholder engagement, and overseeing improvements aligned with NCQA standards. Ideal candidates possess extensive experience in healthcare regulations and operations management, with strong analytical skills.

Qualifications

• Minimum 5 years of experience in health plan operations.
• In-depth knowledge of Medicare and Medicaid regulations.
• Some experience with NCQA accreditation preferred.

Responsibilities

• Manage compliance with Medicare and Medicaid regulations.
• Develop and monitor quality improvement programs.
• Analyze health plan operations for performance improvements.

Skills

Operational Efficiency

Analytical Skills

Problem-Solving

Communication

Stakeholder Management

Education

Bachelor's degree in related field

Certification in healthcare management

Job description

Health Plan Operations Manager - Remote ($150K)

Health Plan Operations Manager - Remote ($150K)

We are seeking a highly motivated and experienced Health Plan Operations Manager to oversee critical components of operational excellence for our health plan. This position requires an individual with strong expertise in health plan operations including ODAG, CDAG, regulatory reporting, and NCQA standards. The ideal candidate will play a pivotal role in ensuring the organization maintains compliance with healthcare regulations while driving performance improvements and enhancing overall efficiency in daily operations.

Key Responsibilities:

Oversight & Compliance:

• Manage and ensure compliance with Medicare and Medicaid regulations, including ODAG (Organization Determinations, Appeals, and Grievances) and CDAG (Coverage Determinations and Appeals).
• Prepare and submit timely and accurate regulatory reports to CMS and other governing authorities.
• Monitor and audit internal processes to ensure adherence to healthcare laws, regulations, and accrediting standards.

NCQA Accreditation:

• Spearhead initiatives to maintain or achieve accreditation and certification through the National Committee for Quality Assurance (NCQA).
• Develop, implement, and monitor quality improvement programs to support certification requirements.
• Serve as a subject matter expert and lead internal readiness for assessments and audits.

Operational Efficiency:

• Analyze health plan operations and performance trends to identify areas for improvement.
• Optimize workflows for appeals, grievances, and determination processes to meet performance metrics and regulatory requirements.
• Create and implement strategies for streamlined collaboration across cross-functional teams.

Stakeholder Engagement:

• Partner with compliance, legal, quality, and clinical teams to strengthen operational performance and ensure transparency in reporting.
• Act as the primary liaison with regulatory bodies and vendors to resolve issues and maintain alignment with health plan standards.
• Train, mentor, and lead a team to uphold operational excellence while supporting professional growth.

Qualifications and Requirements:

• Minimum 5 years of experience in health plan operations (UM/CM/RX or Appeals)
• In-depth knowledge of ODAG, CDAG, Medicare, Medicaid, and other regulatory frameworks.
• Some experience with NCQA accreditation processes and quality improvement initiatives.
• Experience with Compliance initiatives within a health plan relative to CMS regulations.
• Strong analytical, problem-solving, and organizational skills with the ability to manage multiple priorities.
• Excellent communication and stakeholder management skills.

Preferred Skills:

• Expertise in regulatory reporting and data analysis platforms.
• Familiarity with compliance risk management frameworks.
• Must be able to work across different

Seniority level

• Seniority level

  Director

Employment type

• Employment type

  Full-time

Job function

• Job function

  Accounting/Auditing, Consulting, and Management

• Industries

  Hospitals and Health Care and Insurance

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