The TPA Services Manager is responsible for the daily supervision and coordination of core TPA operations, including claims processing, member services and assigned special projects. This role ensures that operational workflows run efficiently, service standards are met, and staff are supported in delivering accurate and timely results. The Manager works closely with the Director of TPA Services to implement departmental goals and serves as a key point of escalation for team leads and staff.
Key responsibilities may include:
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Claims Processing
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Supervise day-to-day claims intake, adjudication, and payment workflows to ensure accuracy and timely turnaround.
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Monitor claims inventory and production queues; identify and resolve backlogs or processing errors.
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Conduct routine audits and quality checks; report error trends and support corrective action plans.
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Assist staff with complex or escalated claims questions; coordinate with plan documents and benefit summaries.
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Ensure claims operations remain compliant with ERISA, HIPAA, and applicable plan requirements.
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Member Services & Call Center
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Oversee daily call center operations including staff scheduling, queue monitoring, and real-time performance tracking.
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Coach and support member services representatives to maintain call quality, accuracy, and professionalism.
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Handle escalated member inquiries, complaints, and grievances in a timely and empathetic manner.
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Track and report on call center KPIs (first-call resolution, handle time, member satisfaction) and flag areas for improvement.
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Special Projects
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Manage assigned operational projects such as process improvement initiatives, system upgrades, or client onboarding support.
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Develop project task lists, coordinate team participation, and track progress against defined timelines.
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Communicate project status updates to the Director and relevant stakeholders.
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Document new or revised workflows and ensure staff are trained on updated procedures.
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Team Leadership & Administration
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Directly supervise TPA operations staff; conduct performance check-ins, provide feedback, and support professional development.
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Assist with onboarding and training of new team members across all functional areas.
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Foster a collaborative, accountable team environment focused on quality and member service.
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Prepare operational reports and dashboards for leadership review on a regular cadence.
Required
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Bachelor’s degree in Business, Healthcare Administration, Insurance, or a related field; or equivalent work experience.
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3–5 years of experience in TPA operations, health insurance claims, or managed care administration.
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1–2 years of supervisory or team lead experience.
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Working knowledge of claims processing, member services operations, and stop loss concepts.
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Familiarity with ERISA, HIPAA, and self-funded health plan administration basics.
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Strong organizational skills and ability to manage multiple priorities in a deadline-driven environment.
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Proficient in Microsoft Office and claims management or benefits administration systems.
Preferred
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Professional certification such as CEBS, AHM, or equivalent.
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Experience with self-funded employer group administration.
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Experience with TPA platforms (e.g., DialPad, ElDorado, or similar).
