Manager, Health Plan Delegation Operations

POSITION SUMMARY

The Manager, Health Plan Delegation Operations runs the day-to-day operational work that keeps Blue Zones Health in good standing with its delegating health plan. The role owns the maintenance, scheduling, and delivery of all recurring health plan reports and required letters; manages health plan communications; leads appeals and grievances (A&G) research; manages delegation committees, joint operating committees (JOCs), and monthly health plan operating calls; and project-manages health plan engagement initiatives.

The Manager reports to the Vice President, Enterprise Operations, and partners closely with the Director, Compliance and Chief Compliance and Legal Officer. The Compliance Director owns annual delegation audit oversight and project management, the master list and maintenance of policies and procedures (P&Ps), compliance oversight of delegation committees, and corrective action plan (CAP) approval, surveillance, communication, and closure. Because audit data originates in operations, the Manager owns audit universe and data pulls and file review preparation, ensures operational processes stay aligned with current P&Ps, and prepares CAP explanations and operational remediation for Compliance's approval. The Manager also tracks health plan action items co-owned by the Compliance Director and the Director, Delegated Operations and Optimization. Success is measured on accurate, complete, on-time delivery, every cycle.

WHY THIS ROLE EXISTS

In a delegated managed care environment, health plans grant BZH the authority to perform functions such as credentialing, utilization management, or claims processing in exchange for ongoing proof that BZH executes those functions to the health plan's standards. That proof takes the form of recurring reports, required letters, timely A&G responses, customer service, and documentation that must be accurate, complete, and delivered on a fixed and often unforgiving schedule. Missed or inaccurate deliverables put BZH at risk of audit findings, corrective action plans, financial penalties, or loss of delegated status.

This Manager was created to run that work day to day: keeping reports and letters current and on schedule, serving as the organized point of contact for health plan communications, researching A&G cases thoroughly and on time, and driving health plan engagement projects and action items to closure.

Budgeted Compensation: $110,000 - $130,000 USD Annually

CORE RESPONSIBILITIES

Health Plan Reports & Letters: Maintenance, Scheduling & Delivery

? Maintain the master calendar of all recurring health plan delegation reports and required letters (daily, weekly, monthly, quarterly, and annual) by health plan and delegated function, as the source of truth for due dates, owners, and status

? Update report and letter templates promptly when a health plan revises its format, data elements, required language, or timeliness standards; maintain version control and communicate changes to affected teams

? Complete report templating and quality assurance from validated data sources

? Schedule production of configured reports in EZ-CAP using a countdown calendar that sequences report generation against each submission deadline

? Route produced reports and letters to the appropriate business leads for validation, manage the correction cycle, and confirm re-validation before release

? Deliver validated reports and letters to each delegating health plan on time, and maintain a submission log evidencing timeliness and completeness

Health Plan Communications

? Serve as the central intake and distribution point for health plan operational communications, including bulletins, requirement changes, data requests, and notices; route them to affected teams and track acknowledgment and response

? Draft and send routine operational correspondence to health plans, such as submission confirmations, data clarifications, and status updates; escalate substantive or position-setting matters to the VP, Enterprise Operations or Compliance Director

? Maintain a health plan communications log and keep the health plan operational contact roster current in partnership with the VP, Enterprise Operations

Appeals & Grievances (A&G) Research

? Research A&G cases and requests referred by health plans, gathering claims, authorization, and provider documentation to prepare complete case files within health plan and regulatory timeframes

? Coordinate with Claims, Utilization Management, and Provider Operations to confirm case facts, and track every case's status and deadline through on-time response

? Trend A&G root causes by health plan, provider, and issue type, and report findings to the VP to inform process improvement and health plan governance discussions

Health Plan Engagement Project Management

? Project-manage health plan engagement initiatives, such as new health plan or line-of-business implementations, delegation agreement changes, and operational improvement projects, with clear plans, owners, timelines, and status reporting

? Contribute and maintain the health plan action-item tracker with the Compliance Director; drive assigned items to closure and flag at-risk items early

Audit Data, File Review & P&P Alignment

? Own universe and data pulls for annual and interim delegation audits, producing complete, accurate data from operational systems to each health plan's audit specifications and timelines

? Own quarterly file reviews and annual file review preparation, pulling and validating the operational data and case files that support each review

? Ensure current and future operational processes align with the P&Ps on Compliance's master list; when P&Ps or processes change, identify gaps, update SOPs, and confirm teams are trained

? Support the annual audit project managed by the Compliance Director by providing reports, letters, and operational documentation on the audit timeline

? Prepare CAP explanations for operational findings, including root cause, corrective actions, and timelines, and submit them to the Chief Compliance and Legal Officer for final approval and health plan communication

? Complete approved operational corrective actions and provide evidence of completion to support Compliance's CAP surveillance and closure

? Keep reporting, letter, communication, and A&G records continuously audit-ready

Delegation Committees, JOCs & Health Plan Operating Calls

? Manage the Quality Management (QM), Utilization Management (UM), Credentialing, and other required delegation committees: scheduling, staffing, agendas, materials, and attendance

? Confirm committee participants hold current, executed participation agreements, and resolve gaps in required attendance or representation

? Manage joint operating committees (JOCs) and monthly operating calls with each delegating health plan, including agendas, performance materials, and follow-up

? Maintain catalogued, audit-ready minutes and supporting materials for all committees, JOCs, and operating calls, and track action items to closure

? Partner with the Compliance Director, who oversees that committees operate compliantly, and remediate any compliance gaps Compliance identifies

Operational Monitoring & Team Development

? Maintain scorecards on reporting and letter timeliness, accuracy, rework, communication turnaround, and A&G timeliness; surface trends and risks to the VP

? Identify recurring gaps or bottlenecks and recommend process improvements, automation, and SOP updates to the VP

? Onboard, train, and supervise delegation operations staff as assigned, and maintain current training materials and SOPs

Compliance

? Comply with all applicable federal, state, and local laws, as well as all Employer policies, procedures, and standards, including but not limited to codes of conduct and ethics requirements, as amended from time to time

ADDITIONAL INFORMATION

Equal Opportunity Employer: This organization is an equal opportunity employer and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, or any other characteristic protected by law.

QUALIFICATIONS

Required

? Bachelor's degree in Healthcare Administration, Business, Nursing, or related field

? 4–6 years of experience in managed care operations, health plan delegation reporting, or MSO/RBO/IPA operations

? 2+ years of experience leading projects or supervising staff

? Experience producing and delivering health plan delegation reports and regulated member or provider letters on fixed deadlines

? Experience researching appeals and grievances cases in a managed care or delegated environment

? Experience producing audit universes and data pulls and preparing files for health plan delegation file reviews

? Experience managing delegation committees (QM, UM, Credentialing) and health plan JOCs or operating meetings, including audit-ready minutes

? Working knowledge of delegated functions (credentialing, UM, claims) and the reporting, letter, and A&G obligations tied to each

? Proficiency with EZ-CAP or comparable managed care platforms, including report configuration and scheduling

? Working knowledge of NCQA, CMS, and applicable state regulatory requirements (e.g., DMHC, DIFS), including A&G and notice timeliness standards

? Strong project management skills and proven ability to manage recurring, deadline-driven work across multiple stakeholders

Preferred

? Master's degree (MHA, MBA, MPH) a plus but not expected

? Project management certification (PMP, CAPM, or equivalent)

? Experience with NCQA delegation oversight standards and HEDIS reporting

? Lean, Six Sigma, or equivalent process improvement exposure