Health Plan Operations Senior Program Manager - REMOTE

Sierra Solutions; New York (NY); Remote; USD 90,000 - 150,000; Full time

Job summary

An established industry player is looking for a Senior Program Manager to lead health plan operations. This remote role involves ensuring regulatory compliance, optimizing client operations, and delivering training sessions. The ideal candidate will have extensive experience in health plan functions and a strong understanding of healthcare regulations. Join a dynamic team dedicated to enhancing service delivery and operational efficiency in the healthcare sector. If you're passionate about making a difference in healthcare solutions, this opportunity is for you.

Qualifications

• 15+ years in health plan operations and regulatory compliance.
• Experience in implementing health plan operations solutions.

Responsibilities

• Support implementation of health plan operational workflows.
• Ensure compliance with HIPAA, ACA, and CMS guidelines.

Skills

Health Plan Operations

Regulatory Compliance

Project Management

Analytical Skills

Healthcare Solutions Implementation

Education

Bachelor's degree in Healthcare Administration

Advanced degree preferred

PMP/PMI certification

Job description

Health Plan Operations Senior Program Manager - REMOTE

Health Plan Operations Senior Program Manager - REMOTE

Job Summary
We are seeking an experienced Senior Program Manager with a deep understanding of health plan operations, regulatory compliance, and hands-on experience in implementing healthcare solutions. This role will support a cross-functional team in implementing multiple transformationalsolutions, ensuring operational efficiency, regulatory adherence, and enhanced service delivery for our clients, with a focus on claims, clinical optimization, and other core operational areas, including the call center, provider, and others.

Primary Responsibilities

• Implementation Support:
  • Assist in implementing critical path work streams (core adj/CM/UM/Enrollment & Eligibility) of a larger transformational solution for health plans, contributing to the seamless integration of processes and systems to meet operational requirements.
  • Collaborate with the project management team and cross-functional stakeholders to ensure alignment with project timelines and deliverables.
• Operational Excellence:
  • Provide expert insights into health plan operations, including claims processing, enrollment, billing, and customer service workflows.
  • Identify areas for improvement within client operations and recommend actionable changes to optimize processes.
• Regulatory Compliance:
  • Ensure all solution components align with local, state, and federal regulatory requirements, including HIPAA, ACA, and CMS guidelines.
  • Conduct compliance audits and assessments, creating reports and action plans to mitigate risk and ensure ongoing regulatory adherence.
• Client Training and Support:
  • Deliver training sessions to client teams on the chosenplatform and related operational procedures.
  • Act as a resource for client inquiries regarding health plan operations and regulatory issues.
• Documentation and Reporting:
  • Develop and maintain comprehensive project documentation, including process flows, compliance checklists, and operational procedures.
  • Generate regular reports for clients and internal teams, outlining project progress, challenges, and next steps.

Job Summary
We are seeking an experienced Senior Program Manager with a deep understanding of health plan operations, regulatory compliance, and hands-on experience in implementing healthcare solutions. This role will support a cross-functional team in implementing multiple transformationalsolutions, ensuring operational efficiency, regulatory adherence, and enhanced service delivery for our clients, with a focus on claims, clinical optimization, and other core operational areas, including the call center, provider, and others.

Primary Responsibilities

• Implementation Support:
  • Assist in implementing critical path work streams (core adj/CM/UM/Enrollment & Eligibility) of a larger transformational solution for health plans, contributing to the seamless integration of processes and systems to meet operational requirements.
  • Collaborate with the project management team and cross-functional stakeholders to ensure alignment with project timelines and deliverables.
• Operational Excellence:
  • Provide expert insights into health plan operations, including claims processing, enrollment, billing, and customer service workflows.
  • Identify areas for improvement within client operations and recommend actionable changes to optimize processes.
• Regulatory Compliance:
  • Ensure all solution components align with local, state, and federal regulatory requirements, including HIPAA, ACA, and CMS guidelines.
  • Conduct compliance audits and assessments, creating reports and action plans to mitigate risk and ensure ongoing regulatory adherence.
• Client Training and Support:
  • Deliver training sessions to client teams on the chosenplatform and related operational procedures.
  • Act as a resource for client inquiries regarding health plan operations and regulatory issues.
• Documentation and Reporting:
  • Develop and maintain comprehensive project documentation, including process flows, compliance checklists, and operational procedures.
  • Generate regular reports for clients and internal teams, outlining project progress, challenges, and next steps.

Education and Experience

• Minimum of 15 years in health plan operations, regulatory compliance, or healthcare consulting.
• Proven experience in implementing core Health Plan Opssolutions and their supporting technology platforms within a Health Plan.
• Blues experience a plus
• Skills and Knowledge:
• In-depth understanding of health plan functions, such as claims processing, member services, provider relations, and care management.
• Comprehensive knowledge of healthcare regulations (e.g., HIPAA, ACA, CMS) and familiarity with audit and compliance processes.
• Strong analytical skills with the ability to interpret regulatory guidelines and assess operational impacts
• Bachelor's degree in Healthcare Administration, Business, or a related field; advanced degree preferred.
• PMP/PMI experience and certifications

Seniority level

• Seniority level

  Director

Employment type

• Employment type

  Full-time

Job function

• Job function

  Project Management

• Industries

  Hospitals and Health Care

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