Healthcare Operations Manager

Healthcare Operations Manager(TPA)

Multi-Year Contract Responsibilities:

• Plan, establish, execute, control, and optimize administrative healthcare business operations associated with a limited public health plan.
• Oversee day-to-day operations of federal Health Program TPA activities, ensuring efficient service delivery and compliance with CMS and federal standards.
• Ensure all operations related to Member and Provider Enrollment, Credentialing, Claims Administration, and Payments are delivered in accordance with SLAs and QASP metrics.
• Drive delivery of business outcomes with the highest quality of care, equity, and stakeholder satisfaction.
• Develop, implement, and monitor operational policies, SOPs, and performance dashboards to continuously improve service quality and program results.
• Coordinate across clinical centers, administrative teams, vendors, and federal stakeholders to ensure seamless execution of program activities.
• Manage budgets, resource allocation, workload distribution, and operational priorities to meet deadlines and ensure fiscal responsibility.
• Monitor performance data, prepare leadership reports, and identify trends, risks, compliance issues, and opportunities for continuous improvement.
• Oversee vendor and contractor performance, ensuring adherence to contractual obligations, SLAs, and compliance with HIPAA, and program requirements.
• Lead operational readiness for new regulations, policies, services, and technology implementations, including change management and training.
• Serve as a primary point of contact for escalated issues, member grievances, and provider concerns, driving timely resolution and root-cause analysis.
• Manage a large team

Required Qualifications:

• Bachelor's degree in healthcare administration, Public Health, Business Administration, or related field (Master's preferred).
• 7–10+ years in healthcare operations management, with at least 3–5 years in federal or public sector health programs (Medicaid, Medicare, VA, DoD, or CDC/NIOSH programs).
• Strong knowledge of healthcare delivery systems, managed care operations, claims processing, and quality improvement methodologies.
• Experience leading large-scale operations in a TPA, Medicaid Enterprise System (MES), or public health program.
• Demonstrated success in managing budgets, contracts, SLAs, and performance metrics in a regulated environment.
• Skilled in vendor/contractor oversight, procurement processes, and performance-based vendor management.
• Strong understanding of healthcare regulations (HIPAA, ACA, Medicaid/Medicare rules, CMS QASP, NIST/FedRAMP security).
• Proficiency with healthcare management systems (provider enrollment systems, claims adjudication systems) and data analytics tools (Power BI, Tableau, etc.).
• Experience managing a large team.
• Ability to obtain and maintain a Public Trust.

Preferred Qualifications:

• Preferred certifications: CPHQ (Certified Professional in Healthcare Quality), PMP (Project Management Professional), Lean Six Sigma, ITIL, or CHC (Certified in Healthcare Compliance).
• Excellent leadership, stakeholder engagement, and change management skills.
• Ability to manage cross-functional teams, including clinical, operational, and IT resources.