Healthcare Project Manager
6 - 10 years
United States
Contract
Remote
1 month ago
About the role
Key Responsibilities:
1. Operating Model Design & Transformation
Define Target Operating Model (TOM) for USFHP/TRICARE Prime environment
Design in-house vs TPA vs vendor responsibilities
Establish end-to-end process frameworks across: Enrollment & Eligibility
Claims & Service Operations
Care Management (UM/CM)
Consumer Engagement / Call Center
Pharmacy / PBM integration
Network Management & Provider Contracting
2. End-to-End Transition & Go-Live Readiness
Lead/support TPA transition (outgoing → incoming vendor) and insourcing programs
Develop transition roadmaps and integrated plans
Define and track go-live readiness across all workstreams
Manage: Data migration and reconciliation
Knowledge transfer (KT)
Parallel run and stabilization (hypercare)
Identify and mitigate transition risks and dependencies
3. Process Design & Operational Build
Develop L3/L4 process maps and SOPs aligned to TRICARE/USFHP requirements
Build end-to-end workflows such as: Member enrollment and onboarding
Referral & authorization (UM workflows)
Claims adjudication and payment
Appeals & grievance handling
Ensure seamless integration across touchpoints (member, provider, plan)
Member journey spans enrollment → care access → claims → appeals
4. Regulatory & Compliance Alignment
Ensure compliance with: TRICARE / DoD guidelines
URAC accreditation standards
HIPAA and data privacy requirements
Support policy & procedure development (SOPs, documentation, audit readiness)
Collaborate with compliance teams on audit and certification readiness
5. Technology & Integration Leadership
Support: Data migration strategy
Interface mapping
UAT and end-to-end testing
Must-Have Experience:
10+ years in healthcare consulting / payer operations
Deep expertise in: USFHP / TRICARE Prime (DoD healthcare programs)
Hands-on experience in: Health plan setup / transformation / TPA transitions
Multi-vendor operating environment (TPA + PBM + digital platforms)
Functional Expertise
Claims administration & adjudication
Care Management (UM/CM, prior authorization)
Enrollment & eligibility (DEERS integration preferred)
Provider network management
Appeals and grievance processes
Preferred Qualifications:
Experience in USFHP plan partnerships / Brighton Marine–like models
Exposure to hybrid (insourced + TPA) operating models
Experience working with: PBMs
Military/retiree population programs
Strong understanding of member/provider journey design
1. Operating Model Design & Transformation
Define Target Operating Model (TOM) for USFHP/TRICARE Prime environment
Design in-house vs TPA vs vendor responsibilities
Establish end-to-end process frameworks across: Enrollment & Eligibility
Claims & Service Operations
Care Management (UM/CM)
Consumer Engagement / Call Center
Pharmacy / PBM integration
Network Management & Provider Contracting
2. End-to-End Transition & Go-Live Readiness
Lead/support TPA transition (outgoing → incoming vendor) and insourcing programs
Develop transition roadmaps and integrated plans
Define and track go-live readiness across all workstreams
Manage: Data migration and reconciliation
Knowledge transfer (KT)
Parallel run and stabilization (hypercare)
Identify and mitigate transition risks and dependencies
3. Process Design & Operational Build
Develop L3/L4 process maps and SOPs aligned to TRICARE/USFHP requirements
Build end-to-end workflows such as: Member enrollment and onboarding
Referral & authorization (UM workflows)
Claims adjudication and payment
Appeals & grievance handling
Ensure seamless integration across touchpoints (member, provider, plan)
Member journey spans enrollment → care access → claims → appeals
4. Regulatory & Compliance Alignment
Ensure compliance with: TRICARE / DoD guidelines
URAC accreditation standards
HIPAA and data privacy requirements
Support policy & procedure development (SOPs, documentation, audit readiness)
Collaborate with compliance teams on audit and certification readiness
5. Technology & Integration Leadership
Support: Data migration strategy
Interface mapping
UAT and end-to-end testing
Must-Have Experience:
10+ years in healthcare consulting / payer operations
Deep expertise in: USFHP / TRICARE Prime (DoD healthcare programs)
Hands-on experience in: Health plan setup / transformation / TPA transitions
Multi-vendor operating environment (TPA + PBM + digital platforms)
Functional Expertise
Claims administration & adjudication
Care Management (UM/CM, prior authorization)
Enrollment & eligibility (DEERS integration preferred)
Provider network management
Appeals and grievance processes
Preferred Qualifications:
Experience in USFHP plan partnerships / Brighton Marine–like models
Exposure to hybrid (insourced + TPA) operating models
Experience working with: PBMs
Military/retiree population programs
Strong understanding of member/provider journey design
Skills
Project ManagementHospitals and Health Care