Manager, Health Operations

Job Code
G1026HF

Department Name
Health Fund Admin

Reports To
Assistant Director, Health Operations

FLSA Status
Exempt

Union Code
N/A

Management
Yes

Job Summary:

Under the direction of the Assistant Director, Health Operations, the Manager, Health Operations plays a key and collaborative role in the delivery of high-quality customer service to our 200,000+ plan participants in support of the 32BJ Health Fund's mission of providing high-quality and low-cost health benefits to union members and their families.

The Manager, Health Operations is responsible for providing operational leadership and subject matter expertise in health plan administration, overseeing vendor and stakeholder relationships, supporting operational performance and process improvement initiatives, and ensuring a shared understanding of Health Fund benefits across internal and external stakeholders. This role partners closely with leadership to enhance service delivery, support strategic initiatives, and leverage operational and claims data to improve the member experience and operational effectiveness.

Essential Duties and Responsibilities:

• Provide operational leadership and guidance to Health Fund staff and cross-functional stakeholders; support staff training, workflow oversight, and implementation of operational best practices

• Lead cross-functional operational workgroups involving Health Services, Member Services, Eligibility, Compliance, Legal, Finance, Information Technology, Analytics, and external vendors; build consensus, facilitate decision-making, and drive accountability for operational initiatives and project deliverables

• Prepare recurring operational reports and executive-level summaries that identify performance trends, unresolved risks, corrective actions, and recommended next steps, and present findings and recommendations to Health Fund leadership as appropriate

• Serve as subject matter expert and manage plan design, medical benefits, cost share information, and take principal responsibility for the following:
  • Monitor and evaluate operational performance, service levels, productivity, quality assurance results, and claims-related metrics; identify trends, recommend operational improvements, and implement corrective actions in partnership with the Assistant Director. Serve as a resource to leadership regarding operational risks, opportunities, and service delivery performance.
  • Manage day-to-day operational relationships with the Fund's third-party administrators, provider networks, and other health vendors, including monitoring operational performance, tracking performance guarantees, key performance indicators, service-level agreements, open issues, and corrective-action commitments, and escalating significant operational concerns to Health Fund leadership
  • Ensure Health Fund staff, Member Service Representatives, and external shareholders all maintain a shared understanding about the covered benefits with regard to what benefits are covered, how claims are processed, and what limitations apply to covered benefits
  • Review and revise plan documents (including Summary Plan Descriptions, Summary of Benefits and Coverage) as needed
  • Understand and operationally apply the rules of health plan design in order to resolve plan participant related matters
  • Partner internally and with the Fund's Third-Party Administrator (TPA) to track, document and maintain updates and changes to the Fund's medical plan designs
  • Work with Health Fund staff to monitor inquiries and complaints resulting from systemic problems, such as miscoding of benefit categories or improper implementation of benefits to follow Health Fund's plan documents
  • Lead the investigation and resolution of escalated member, provider, benefit, and claims-administration issues, coordinating with vendors and internal departments and escalating material risks
  • Monitor operational compliance with the Summary Plan Descriptions, Summary of Material Modifications, benefit summaries, Fund policies, contractual requirements, HIPAA requirements, and applicable service standards
  • Develop and maintain quality-control processes to identify benefit configuration, claims-processing, documentation, and service-delivery errors; establish corrective-action plans and monitor them through completion

• Develop, maintain, and enhance the Health Fund portions of the 32BJ Benefit Funds member portal and the internal CRM
  • Meet with enterprise stakeholders and end users to identify, prioritize, understand and document business and technical processes and requirements
  • Facilitate process workflow modeling in order to collaborate on process improvements, automation capabilities and clearly defined end-to-end use cases
  • Develop process documentation/workflows outlining current state and future state, knowledge articles and self-service guidance
  • Provide ongoing portal and CRM training to Health Services staff
  • Track major incident management process and ensure adherence of the process and escalation requirements within the various support and delivery areas
  • Coordinate operational readiness for benefit changes, plan-design updates, vendor implementations, system enhancements, and regulatory or organizational initiatives, including testing, documentation, communications, training, and post-implementation monitoring
  • Coordinate user-acceptance testing and validate vendor benefit configurations and system changes against approved plan provisions and business requirements
  • Develop, maintain, and periodically review operational policies, standard operating procedures, workflows, escalation protocols, knowledge articles, and other documentation supporting Health Fund Operations
  • Identify issues and risks, and maintain trackers for issues, risks, decisions, and implementation items and perform root-cause analysis of recurring complaints, processing defects, and operational incidents
  • Recommend process automation, workflow redesign, and system improvements that improve accuracy, efficiency, and the member experience

• Identify, develop, and lead engagement opportunities for plan participants
  • Analyze claims data and operational data to identify member education campaigns
  • Implement campaigns into call center scripting, CRM functionality and portal functionality
  • Advise and provide additional support to the Health Operations team

• Support audits, compliance reviews, and responses to operational document and data requests
  • Support vendor evaluations, implementation planning, contract-performance reviews, and follow-up on operational commitments arising from Request for Proposal initiatives

• Provide functional leadership to project teams, operational stakeholders and serve as a designated backup to the Assistant Director, Health Operations, ensuring continuity of operations, stakeholder coordination, and issue resolution

• Perform other relevant duties as assigned by management and senior leadership

Qualifications (Competencies):

• 3+ years experience in business process re-engineering, requirements definition, process analysis and design, workflow analysis, and developing As-Is and To-Be business processes

• 3+ years experience in health benefits administration from the provider and/or payer perspective

• Demonstrated experience leading projects, workgroups, or operational initiatives in a health benefits, healthcare, or health plan environment

• Prior experience in developing workflow, case management, CRM and document management systems

• Strong ability to propose and develop process improvement strategies using operational and performance data

• Excellent MS Office skills including Visio, PowerPoint and Project

• Demonstrated ability to create project plans, manage scope and schedule for portal/CRM and other projects

• Operational understanding of claim processing and provider reimbursement preferred

• Experience managing vendor performance, service-level agreements, key performance indicators, and corrective-action plans

• Experience mentoring, coaching, training, or providing functional guidance to staff, project teams, or cross-functional workgroups

Soft Skills (Interpersonal Skills):

• Ability to independently asses operational issues, exercise sound judgement, and recommend solutions that support department goals and service objectives

• Detail oriented with excellent organization, presentation, critical and analytical thinking, communication, and problem-solving skills

• Strong leadership and collaboration skills

• Ability to plan and take initiatives to accomplish objectives in timely fashion

• Ability to establish and maintain effective working relationships with project team members, supervisors, and employees from other departments

Education:

Bachelor's degree in a related field (e.g. Public Health, Psychology, Health Administration) or combined work experience and education required.

Master's degree preferred.

Language Skills:

Reasoning Ability:

High

Certificates, Licenses, Registrations:

Shift

Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals to perform the essential functions.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals to perform the essential functions.

• Under 1/3 of the time: Standing, Walking, Climbing or Balancing, Stooping, Kneeling, Crouching, or Crawling
• Over 2/3 of the time: Talking or Hearing
• 100% of the time: Using Hands

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• 1/3 to 2/3 of the time: Work near moving or mechanical parts, exposure to radiation, moderate noise.