Claims/Enrollment Operations Manager

at  Harbor Health

Harbor Health looking for an experienced Claims/Enrollment Operations Manager to become a member of our team! Harbor Health is an entirely new multi-specialty clinic group in Austin, TX utilizing a modern approach to co-create health with those who get, give, and pay for it, allowing everyone to fully flourish. Join us as we build a fully integrated system that connects care to a better payment model that truly puts the human being at the center.
The Claims/Enrollment Operations Manager is responsible for the oversight of Harbor’s TPA who is processing transactional data on behalf of Harbor members. The assurance of timely and accurate processing of data is critical to member and provider satisfaction along attainment of all Texas Department of Insurance requirements. This position is critical for both implementation and business operations of the Harbor insurance plan.

Our Claims/Enrollment Operations Manager will be responsible for:

• Review and validate System Configuration of Benefits, Claims and Member
• Validate and approve TPA’s UAT test cases.
• Create, process, and validate claims and member test cases.
• Review and approve claims and enrollment processing instructions.
• Coordinate development of Operational Reports with TPA and Harbor Health
• Review and approve EOB, EOP, Claims and Member processing codes.
• Coordinate development of Operational Reports with TPA and Harbor Health.
• Daily review of Claims and Members processing statuses. Identify any issues and coordinate with TPA the resolution of issues.
• Sampling review of claims processed, member updates, ID cards, letters, EOBs and EOPs on vendor’s sites. Identify and issues and coordinate resolution with appropriate parties.
• Coordination with appropriate partners of any member/provider inquiries, complaints, group, or state audits.
• Approval of designated “high dollar” claims.
• Audit a sampling of claims in finalized status. Identify any issues and coordinate with TPA on resolution and training.
• Track and report on assigned implementation milestones and tasks.
• Coordinate, audit, and approve TPAs security roles, functions, and people.
• Other duties as assigned.

Successful Claims/Enrollment Operations Managers will have:

• 7 years of relevant healthcare experience, particularly with regard to health plan operations and technology
• Demonstrated success operating high-growth companies
• Data analysis skills including the ability to pull data from source systems
• Demonstrated creativity in identifying and implementing solutions to complex, ambiguous issues.
• Ability to act as a team player
• Ability to manage outside vendor relationship
• Have the ability to partner in the development, management and operationalizing processes and workflows to maximize efficiencies.
• This is a remote role

Additional Skills & Experiences Preferred include:

• Strong knowledge of state claims/members processing rules and regulations.
• Experience implementing and operating delegated TPA, UM, UR, credentialing and related functions
• Knowledge of benefit plans design, EOC and other applicable documents.
• Experience developing and administering value-based payment arrangements a plus
• Masters in Healthcare or Business Administration or other related fields

Physical Requirements of the role include:

• Up to 25% travel

If you are passionate about health care and you want to create something new together, we want you to be apart of our team!
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Our Claims/Enrollment Operations Manager will be responsible for:

• Review and validate System Configuration of Benefits, Claims and Member
• Validate and approve TPA’s UAT test cases.
• Create, process, and validate claims and member test cases.
• Review and approve claims and enrollment processing instructions.
• Coordinate development of Operational Reports with TPA and Harbor Health
• Review and approve EOB, EOP, Claims and Member processing codes.
• Coordinate development of Operational Reports with TPA and Harbor Health.
• Daily review of Claims and Members processing statuses. Identify any issues and coordinate with TPA the resolution of issues.
• Sampling review of claims processed, member updates, ID cards, letters, EOBs and EOPs on vendor’s sites. Identify and issues and coordinate resolution with appropriate parties.
• Coordination with appropriate partners of any member/provider inquiries, complaints, group, or state audits.
• Approval of designated “high dollar” claims.
• Audit a sampling of claims in finalized status. Identify any issues and coordinate with TPA on resolution and training.
• Track and report on assigned implementation milestones and tasks.
• Coordinate, audit, and approve TPAs security roles, functions, and people.
• Other duties as assigned