Operations Lead

About the Role

We are looking for a seasoned Operations Excellence Lead to enhance operational efficiency, service quality, and continuous improvement within a growing healthcare organization. This pivotal role ensures that operational processes consistently deliver outstanding experiences to members, providers, employer groups, brokers, and internal teams while maintaining compliance with regulatory standards.

This leadership position collaborates closely with executive management to boost accountability, optimize workflows, and translate strategic plans into actionable outcomes. The right candidate thrives in a dynamic setting, adept at leading cross-department initiatives and driving sustained operational enhancements.

Key Responsibilities

• Foster a culture prioritizing excellent customer service and operational excellence.
• Lead the resolution of intricate issues involving members, providers, clients, and brokers.
• Track complaints, appeals, grievances, and service trends to spot areas for improvement.
• Create corrective action strategies to enhance satisfaction and prevent repeat issues.
• Collaborate with Customer Service management to boost responsiveness and resolve issues on first contact.
• Supervise claims performance, inventory levels, turnaround timelines, quality benchmarks, and backlog management.
• Coordinate multidisciplinary teams to tackle complex claims processing challenges.
• Perform root cause analyses to identify persistent problems and implement lasting fixes.
• Discover opportunities to improve workflows, automate tasks, and increase operational efficiency.
• Ensure benefit configuration updates and operational improvements are correctly deployed and verified.
• Oversee vendor and third-party administrator relationships to maintain service levels.
• Evaluate vendor performance based on SLAs and KPIs.
• Lead operational assessments and initiatives for performance enhancement.
• Keep track of contracts, milestones, renewals, and compliance obligations tied to operations.
• Maintain vendor scorecards to measure service quality, turnarounds, and operational results.
• Manage a centralized dashboard of operational projects, responsibilities, and deadlines.
• Ensure meetings end with clear action plans, designated owners, and deadlines for tasks.
• Detect operational risks, identify procedural gaps, and replace single points of failure with sustainable fixes.
• Document and standardize workflows to enhance consistency and information sharing.
• Handle urgent operational escalations from clients, brokers, and internal units until resolved.
• Escalate operational risks accompanied by realistic recommendations and concrete actions.

Reporting and Analytics

• Develop and maintain dashboards that track customer and provider satisfaction metrics.
• Monitor claims processing times, accuracy, and backlog statuses.
• Track vendor performance and SLA adherence.
• Report on operational backlogs and ongoing improvement projects.

Provide management with frequent operational reports, trend analyses, insight into performance, and strategic advice.

Qualifications

• Bachelor's degree in Business Administration, Healthcare Administration, Operations Management, or closely related discipline.
• At least five years of progressive leadership experience in healthcare operations, managed care, health insurance, or another stringent regulatory service sector.
• Proven track record of leading operational improvement projects and managing complex initiatives from inception through completion.
• Experience managing customer service, claims workflow, and operational performance measurement programs.
• Strong skills in influencing cross-functional teams and enforcing accountability without direct authority.
• Experience in managing vendor partnerships and operational contract lifecycles.