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About the Role

The Manager, Health Operations plays a key and collaborative role in delivering high-quality customer service to plan participants, supporting the 32BJ Health Fund’s mission of providing high-quality, low-cost health benefits. This role provides operational leadership, subject matter expertise in health plan administration, oversees vendor and stakeholder relationships, and supports operational performance and process improvement initiatives.

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 various departments 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 identifying performance trends, risks, and corrective actions.
Present findings and recommendations to Health Fund leadership.
Serve as subject matter expert and manage plan design and medical benefits.
Monitor and evaluate operational performance, service levels, productivity, quality assurance results, and claims-related metrics.
Identify trends, recommend operational improvements, and implement corrective actions.
Serve as a resource to leadership regarding operational risks, opportunities, and service delivery performance.
Manage day-to-day operational relationships with third-party administrators, provider networks, and other health vendors.
Monitor vendor operational performance, track performance guarantees, KPIs, and SLAs.
Escalate significant operational concerns to Health Fund leadership.
Ensure Health Fund staff, Member Service Representatives, and external shareholders maintain a shared understanding of covered benefits.
Review and revise plan documents, including Summary Plan Descriptions and Summary of Benefits and Coverage.
Operationally apply health plan design rules to resolve participant-related matters.
Track, document, and maintain updates and changes to the Fund’s medical plan designs in partnership with the TPA.
Monitor inquiries and complaints resulting from systemic problems and follow Health Fund’s plan documents.
Lead the investigation and resolution of escalated member, provider, benefit, and claims-administration issues.
Coordinate with vendors and internal departments and escalate material risks.
Monitor operational compliance with 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 errors in benefit configuration, claims processing, documentation, and service delivery.
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 to collaborate on process improvements, automation capabilities, and defined use cases.
Develop process documentation/workflows outlining current and future states, knowledge articles, and self-service guidance.
Provide ongoing portal and CRM training to Health Services staff.
Track major incident management process and ensure adherence to process and escalation requirements.
Coordinate operational readiness for benefit changes, plan-design updates, vendor implementations, system enhancements, and regulatory or organizational initiatives.
Coordinate user-acceptance testing and validate vendor benefit configurations and system changes.
Develop, maintain, and periodically review operational policies, standard operating procedures, workflows, escalation protocols, and knowledge articles.
Identify issues and risks, and maintain trackers for issues, risks, decisions, and implementation items.
Perform root-cause analysis of recurring complaints, processing defects, and operational incidents.
Recommend process automation, workflow redesign, and system improvements.
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.
Provide functional leadership to project teams and operational stakeholders.
Serve as a designated backup to the Assistant Director, Health Operations.
Perform other relevant duties as assigned by management and senior leadership.

Requirements

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.
Ability to independently assess operational issues, exercise sound judgment, and recommend solutions.
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 a timely fashion.
Ability to establish and maintain effective working relationships with project team members, supervisors, and employees from other departments.

Skills

Business process re-engineering
Requirements definition
Process analysis and design
Workflow analysis
Health benefits administration
Project leadership
Operational initiatives
Workflow systems
Case management systems
CRM systems
Document management systems
Process improvement strategies
MS Office Suite (Visio, PowerPoint, Project)
Project planning
Scope management
Schedule management
Claim processing
Provider reimbursement
Vendor performance management
Service-level agreements (SLAs)
Key Performance Indicators (KPIs)
Corrective action plans
Mentoring
Coaching
Training
Functional guidance
Operational issue assessment
Judgment
Solution recommendation
Organization
Presentation
Critical thinking
Analytical thinking
Communication
Problem-solving
Leadership
Collaboration
Initiative
Relationship building

Location

Work Type

Exempt

Experience Level

3+ years experience in business process re-engineering
3+ years experience in health benefits administration
Prior experience in developing workflow, case management, CRM and document management systems
Experience managing vendor performance
Experience mentoring, coaching, training, or providing functional guidance

Education Level

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.

About the Company

Building Services 32BJ Benefit Funds (“the Funds”) is the umbrella organization responsible for administering Health, Pension, Retirement Savings, Training, and Legal Services benefits to over 185,000 SEIU 32BJ members.
Our mission is to make significant contributions to the lives of our members by providing high quality benefits and services.
Through our commitment, we embody five core values: Flexibility, Initiative, Respect, Sustainability, and Teamwork (FIRST).
The Funds oversees and manages $11 billion of dollars in assets, which are made up of many, varied and complex funds.
32BJ Benefit Funds will continue to drive innovation, equity, and technology insights to further help the lives of our hard-working members and their families.
We use cutting edge technology such as: M365, Dynamics 365 CRM, Dynamics 365 F&O, Azure, AWS, SQL, Snowflake, QlikView, and more.