Sr Program Manager, MSO Operations

Position Summary

The Senior Program Manager, MSO Operations is responsible for overseeing the ongoing optimization and seamless functioning of the MSO’s operational units, with a strong focus on Claims Operations, EDI, Eligibility, Capitation, and other core MSO functions. This role ensures that operational processes run efficiently, are technologically enabled, and remain compliant with regulatory standards under Medicare Advantage full-risk value-based care contracts.

The Senior Program Manager will play a central role in transitioning new clients into the MSO, leading project management for operational and technology initiatives (e.g., EFT automation, retroactive kickouts (RKK) optimization, mailroom efficiencies), and enabling the future state of fully tech-enabled MSO operations.

This individual serves as the bridge between operational leadership, technology teams, and client-facing functions, ensuring projects are executed on time, within scope, and aligned with the strategic vision of the MSO.

Key Responsibilities

Operational Oversight & Optimization:

• Monitoring of the day-to-day operations of Claims, EDI, Eligibility, and Capitation units to ensure smooth functioning and resolution of escalated issues.
• Drive continuous improvement in operational workflows, ensuring efficiency, accuracy, and scalability to support growth.
• Monitor key performance indicators (KPIs) across Claims, Eligibility, and Capitation, providing data-driven insights to leadership.
• Partner with Compliance, Finance, and Clinical Operations teams to ensure processes align with CMS and payor requirements under Medicare Advantage full-risk VBC contracts.

Client Onboarding & Transition Management:

• Lead the operational integration and transition of new IPA clients into the MSO platform.
• Collaborate with cross-functional teams (Credentialing, Contracting, Provider Relations, IT) to ensure seamless onboarding.
• Develop standardized transition playbooks and timelines to manage risks, dependencies, and deliverables.
• Act as the operational point of contact for client onboarding, addressing issues proactively and ensuring successful handoffs.

Program & Project Management:

• Lead project management efforts for operational improvement initiatives, including but not limited to:
  • EFT automation and optimization (payment workflows).
  • Mailroom and document management efficiencies.
  • System integrations and tech enablement of Claims/MSO operations.
• Establish project timelines, budgets, deliverables, and success metrics.
• Manage cross-departmental teams, ensuring accountability and clear communication of project goals.
• Regularly report project progress, risks, and results to the VP of MSO Operations and executive leadership.

Technology Enablement:

• Partner with IT, vendors, and internal stakeholders to ensure the deployment of technology solutions that streamline MSO operations (claims adjudication, eligibility verification, EDI transactions, document management, analytics dashboards).
• Serve as business lead for system upgrades, implementations, and automation efforts in MSO operations.
• Identify and prioritize areas where technology can drive efficiency, accuracy, and scalability in claims and related functions.
• Develop and maintain a roadmap for operational technology enablement aligned with organizational strategy.

Leadership & Collaboration:

• Provide mentorship and operational guidance to managers and supervisors within Claims, Eligibility, and Capitation teams.
• Cultivate a culture of accountability, process improvement, and cross-functional collaboration.
• Work closely with Compliance and Audit teams to ensure adherence to CMS, HIPAA, and other regulatory standards.
• Partner with Finance to ensure capitation payments, eligibility reconciliations, and claims processing align with financial accuracy and timeliness goals.

Qualifications:

Education & Experience

• Bachelor’s degree in Healthcare Administration, Business Administration, or related field (Master’s preferred).
• 7 years of experience in healthcare MSO or health plan operations, with significant exposure to Claims, Eligibility, EDI, and Capitation functions.
• 5 years of progressive leadership or program/project management experience.
• Demonstrated experience in managing large-scale operational transitions and client onboarding.
• Proven track record in implementing technology solutions within healthcare operations.

Skills & Competencies

• Deep understanding of Medicare Advantage full-risk value-based care operations and compliance requirements.
• Strong program and project management skills (PMP certification preferred).
• Excellent analytical skills with ability to interpret data, identify trends, and drive process improvements.
• Strong communication, stakeholder management, and cross-functional leadership skills.
• Proficiency with claims adjudication systems, EDI platforms, eligibility/capitation systems, and reporting tools.
• Ability to balance strategic thinking with operational execution.

Performance Metrics

• Operational KPIs: Claims turnaround time, accuracy rates, EDI transaction success rates, eligibility reconciliation timeliness, capitation accuracy.
• Successful client onboarding within agreed-upon timelines and satisfaction benchmarks.
• Completion of key initiatives (EFT, RKK, mailroom, tech enablement) within scope, budget, and timelines.
• Improvement in operational efficiency, cost savings, and scalability.
• Compliance with CMS, HIPAA, and internal audit standards.

AMM BENEFITS

When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:

• Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.
• Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.
• Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
• Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.
• Career Development: Tuition reimbursement to support your education and growth.
• Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun!

Join AMM and experience a workplace where your health, growth, and happiness comes first!