TPA Operations SME- REMOTE

Job Summary
We are seeking an experienced and strategic TPA Operations SME to oversee and drive operational excellence across our third-party administration services. In this leadership role, you will be responsible for the performance, scalability, and continuous improvement of our operational teams supporting health plan administration-including claims, eligibility, customer service, and compliance. The ideal candidate will have a strong background in healthcare operations, team leadership, client management, and process optimization.

Primary Responsibilities

• Provide strategic leadership and oversight for day-to-day TPA operations, ensuring high levels of service delivery, accuracy, and compliance.
• Lead and manage department heads across claims, eligibility, customer service, provider relations, and implementation teams.
• Develop and implement operational policies, procedures, and performance metrics to support scalability and efficiency.
• Partner closely with sales, client management, and implementation teams to ensure seamless onboarding and long-term client satisfaction.
• Monitor KPIs and SLAs to ensure contractual and regulatory requirements are consistently met or exceeded.
• Oversee vendor relationships and system integrations related to claims adjudication, eligibility management, EDI, and other TPA functions.
• Drive initiatives to automate processes, reduce costs, and improve turnaround times across departments.
• Ensure ongoing compliance with federal and state regulations, including ERISA, HIPAA, ACA, and others relevant to health plan administration.
• Prepare and present regular performance reports to senior leadership and key stakeholders.
• Foster a culture of accountability, collaboration, and continuous improvement across the organization.

Education and Experience

• Bachelor's degree in Business Administration, Healthcare Management, or a related field (Master's degree preferred).
• 8+ years of progressive leadership experience within a TPA or health plan environment.
• Proven experience managing multi-functional operations teams in a regulated healthcare setting.
• Deep understanding of benefit administration, including self-funded plans, claims processing, provider networks, and compliance requirements.
• Strong leadership and people management skills, with the ability to mentor, coach, and build high-performing teams.
• Excellent analytical, decision-making, and problem-solving skills.
• Proficiency in health plan administration platforms and reporting tools.
• Strong communication and presentation skills, with experience engaging with executive leadership and key clients.
• Experience with union, Taft-Hartley, or multi-employer benefit plans.
• Familiarity with core TPA platforms (e.g., HealthEdge, Plexis, WEX, etc.).
• Project Management certification (PMP) or Six Sigma certification.