COPE Health Solutions Careers

Description

• Direct and oversee all internal and subcontracted operational functions of the MSO/TPA, including utilization management, care management, credentialing, quality improvement, call center/member services, enrollment, claims administration, configuration, provider network and data operations, and operational analytics.
• Establish and maintain standardized policies, procedures, controls, and workflows to drive efficiency, consistency, and regulatory compliance.
• Lead operational performance management through defined KPIs, service levels, dashboards, and continuous improvement initiatives.
• Serve as an executive decision‑maker for operational policies, workflows, and resourcing decisions within approved strategy and budget.
• Identify operational investments, infrastructure changes, and remediation actions impacting enterprise performance.

• Manage contractual, operational, and performance relationships with clients, delegated entities, and key vendors.
• Ensure adherence to contractual requirements, service‑level agreements (SLAs), quality standards, and regulatory obligations.
• Lead vendor selection, contracting support, performance remediation, and ongoing operational governance.
• Serve as the executive authority for vendor and delegate issue escalation, resolution, and corrective action approval.

• Partner with Finance to develop and manage operating budgets, forecasts, and cost‑containment initiatives.
• Own operational P&L, including expense controls, productivity metrics, and margin optimization.
• Identify operational efficiencies and scalability opportunities that drive financial sustainability.
• Maintain accountability for operational cost structure design, staffing models, and productivity optimization.
• Partner with the CEO and CFO to align operational performance with enterprise financial goals and growth strategy.

• Ensure compliance with federal, state, and payer regulations (e.g., CMS, Medicaid, delegated functions).
• Oversee delegation oversight, audit readiness, regulatory findings, corrective action plans, and internal controls.
• Promote a culture of quality, accuracy, and risk awareness across all operational teams.

• Translate organizational strategy into executable operational plans and measurable outcomes.
• Align disparate operational functions into a unified strategy that supports organizational growth and compliance.
• Lead operational aspects of growth initiatives, including new lines of business, new markets, acquisitions, integrations, and system implementations.
• Drive process improvement, automation, and technology modernization across core operational functions.
• Ensure operational scalability and organizational readiness to support strategic growth and market expansion.

• Build, lead, and develop a high‑performing operational leadership team.
• Establish clear accountability structures, performance expectations, and professional development pathways.
• Foster a culture of collaboration, ownership, and continuous improvement.
• Design the operational organizational structure to support future growth, succession planning, and long‑term enterprise maturity.

• Serve as a key advisor to the CEO and leadership team on operational performance, risks, and opportunities.
• Prepare and present operational updates, metrics, and recommendations to executive leadership and governing bodies.
• Collaborate with internal and external stakeholders, including payers, providers, regulators, vendors, and partners.
• Represent operations in executive, Board, and committees as assigned by the CEO.

• Bachelor’s degree in Healthcare Administration, Business Administration, or a related field (Master’s degree or MBA strongly preferred).
• Minimum of 15+ years of progressive leadership experience in MSO, TPA, managed care, health plan, or healthcare operations.
• Experience overseeing large‑scale, complex healthcare operations and delegated functions with enterprise‑level accountability.
• Experience supporting Medicaid Managed Care, Medicare Advantage, and/or Commercial health plans.
• Prior accountability for MSO/TPA performance management and delegated operations.

• Experience leading growth initiatives, system implementations, integrations, or operational turnarounds.
• Familiarity with healthcare administration platforms (claims, enrollment, UM, CRM, reporting tools).

• Deep understanding of managed care operations, TPA administration, and healthcare regulatory requirements.
• Strong financial acumen, including budgeting, forecasting, and operational cost management.
• Proven ability to lead cross‑functional teams and execute change in complex environments.
• Experience with operational analytics, performance metrics, and continuous improvement methodologies.
• Excellent communication, negotiation, and stakeholder management skills.

• Strategic thinker with strong execution discipline
• Results‑oriented and data‑driven
• Collaborative, decisive, and accountable
• High integrity and commitment to compliance and quality
• Comfortable operating in fast‑paced, highly regulated environments