What are the responsibilities and job description for the TPA Operations SME- REMOTE position at Sierra Solutions?
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.
