Job Description

The Head of TPA Operations is a senior, hands-on leader responsible for the end-to-end delivery of health insurance claims services. This role assumes ultimate ownership for the entire lifecycle of claims and adjacent TPA functions, including payment integrity, provider data management, and all associated regulatory and financial reporting. The ideal candidate will have deep expertise in health insurance payor operations and a proven track record of driving efficiency, accuracy, and proactive compliance in a TPA environment.

Essential Duties and Responsibilities

• Operational Leadership & Delivery:
• Oversee all day-to-day TPA operations, including claims processing, payment integrity, and provider data management, ensuring timely, accurate, and compliant delivery across all lines of business.
• Assume ultimate ownership for ensuring that all operational activities, including all necessary reporting, data generation, and tax filings, are performed accurately and on time. Develop and maintain a comprehensive operational calendar to track and manage all deliverables and deadlines.
• Regulatory Foresight and Strategy:
• Act as the primary subject matter expert on all TPA-related operational and regulatory obligations. Proactively monitor, interpret, and implement the full spectrum of federal and state requirements, including federal and state data transparency mandates, all required tax and financial reporting obligations, ERISA, and HIPAA.
• Payment Integrity:
• Lead and oversee all payment integrity functions, including fraud, waste, and abuse (FWA) detection, prevention, and recovery efforts.
• Develop and implement strategies to enhance payment accuracy and reduce claim overpayments.
• Provider Data Management:
• Direct the management of provider data, ensuring accuracy and timeliness of provider credentialing and demographic information.
• Oversee the implementation of new provider contracts and fee schedules.
• Compliance & Reporting:
• Ensure all processes and procedures are fully compliant with all applicable healthcare regulations, including HIPAA, ERISA, and CMS guidelines, with a strong focus on claims-related compliance.
• Establish and maintain robust internal controls and auditing procedures to ensure operational and regulatory integrity.
• Strategic Planning & Client Management:
• Partner with senior leadership to develop and execute the strategic vision for the TPA claims function.
• Serve as the key point of contact for clients on all matters related to claims operations, providing expert guidance and ensuring high levels of client satisfaction.

͏

Education and Experience

• Bachelor’s degree in Business Administration, Health Administration, or a related field required; Master’s degree preferred.
• Minimum of 10-15 years of progressive experience in health insurance payor operations, with at least 5 years in a senior leadership role overseeing TPA functions.
• Demonstrated, hands-on experience managing the full scope of TPA responsibilities across multiple, complex lines of business, including ASO, fully insured, and government programs (e.g., Medicare, ACA).
• Proven track record of ensuring timely and accurate filing of all required regulatory data submissions and all financial/tax-related reporting.
• Demonstrated experience managing payment integrity functions, including FWA programs.
• Proven experience with provider data management processes within a TPA or health plan environment.
• In-depth knowledge of claims processing systems, industry best practices, and relevant federal and state regulations.
• Exceptional leadership, communication, and problem-solving skills.

͏

͏

͏