Job Description

Network Partner (TPA) Operations Manager

The TPA Business Manager is responsible for overseeing the effective delivery and performance of MaxHealth’s operational services through its dedicated TPA units – the 800CallMax Team and the 800MaxNet Team. Acting as the primary operational liaison between MaxHealth and its Third-Party Administrators (TPAs), the role ensures consistent service delivery, operational efficiency, contractual compliance, and continuous improvement across customer service, call center operations, prior authorization, claims administration, provider network support, and member services. The role will also oversee and coordinate provider network-related matters, working closely with TPAs to address provider escalations, cost containment, identify network accessibility, and service gaps, monitor recurring provider-related issues, and support timely corrective actions and network enhancements to ensure a seamless healthcare experience for MaxHealth members.

Key Responsibilites:

TPA Operations & Service Delivery

Oversee and coordinate the daily operational performance of the 800CallMax and 800MaxNet Teams.

Act as the central point of contact between MaxHealth, internal stakeholders, and TPAs for operational matters.

Ensure adherence to MaxHealth policies, procedures, service standards, and Corporate Identity (CI) requirements.

Identify operational gaps, escalate critical issues, and ensure timely implementation of corrective actions and agreed initiatives.

Call Center & Customer Experience

Oversee TPA call center performance and monitor key customer experience indicators, including Service Level, Voice of Customer, Customer Satisfaction, and Quality Scores.

Review complaints, escalations, call quality findings, and root causes to identify improvement opportunities.

Coordinate training, corrective actions, and service enhancement initiatives to improve customer satisfaction and NPS.

Prior Authorization, Claims & Provider Network Oversight

Monitor operational performance across prior authorization, claims, reimbursement, and related healthcare operations.

Track turnaround times, pending cases, service bottlenecks, and compliance with agreed SLAs.

Coordinate provider network-related matters with TPAs, including provider escalations, accessibility gaps, recurring service issues, and required corrective actions.

Support workflow optimization, automation initiatives, and operational enhancements.

Performance Management & Continuous Improvement

Monitor contractual KPIs and SLAs and analyze operational trends and performance gaps.

Prepare regular management reports and coordinate business review meetings with TPAS.

Follow up on agreed action plans and ensure timely completion.

Identify opportunities for process improvement, automation, digital transformation, and enhanced operational efficiency.

Qualifications & Experience

Bachelor’s degree in business administration, Healthcare Management, Insurance, or a related field.

Minimum 5 years of relevant experience in health insurance, healthcare administration, or TPA operations.

Experience managing outsourced operations and overseeing customer service or call center functions.

Strong understanding of medical claims, prior authorization, provider network operations, and healthcare service delivery.

Experience in KPUSLA management, operational reporting, and performance improvement.

Skills & Competencies

Strong stakeholder and relationship management skills.

Analytical, problem-solving, and decision-making capabilities.

Strong customer focus and operational excellence mindset.

Performance management, project coordination, and process improvement skills.

Data analysis and management reporting capabilities.

Excellent communication, organizational, and planning skills.

Ability to manage multiple priorities with strong attention to detail.

Advanced Microsoft Excel and PowerPoint skills.

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