Vaco by Highspring · 1 week ago
Product Manager, TPA/Claims ($130,000)
United States
Full-time
Remote
Mid, Senior Level
$120K/yr - $130K/yr
5+ years expVaco by Highspring is a rapidly growing healthcare organization seeking a Product Manager to own the strategy, roadmap, and delivery of its Claims Processing Platform. The role involves translating operational goals and regulatory requirements into product outcomes and collaborating with both business stakeholders and engineering teams to enhance claims processing efficiency and compliance.
Staffing & Recruiting
Hiring Manager
Brittany Greco
Responsibilities
Own product strategy across claims intake, validation, adjudication, pricing, payment, remittance, audit, and related integrations (EHR, Enrollment, UM, Risk, Quality, Coding Scrubber)
Define and maintain a quarterly roadmap aligned to business OKRs, regulatory timelines, and client commitments
Partner with Ops, Compliance, Finance, and Technology to align and socialize priorities
Convert operational goals and regulatory constraints into epics, features, and user stories with strong acceptance criteria, edge cases, and non-functional requirements (auditability, throughput, security, privacy)
Lead backlog grooming and sprint planning with engineering; ensure requirements are unambiguous and testable
Act as product SME across the claims lifecycle; design claim edits and reference data strategies (pricing rules, COB/TPL, provider/plan configuration)
Specify and validate EDI/X12 transactions including: 837 (P/I/D), 835, 270/271, 276/277, 278 ; coordinate with clearinghouses and trading partners
Support standards/interoperability (HL7/FHIR, NCPDP for pharmacy)
Drive UAT with Claims Ops; establish release gates for compliance, performance, and data quality (PHI handling, audit logs, error rates)
Partner with QA on scenario-based testing and data validation for adjudication rules, pricing, and remittance
Ensure adherence to HIPAA/HITECH, CMS guidance (including Medicare Advantage considerations), ERISA/state requirements, and internal security controls (RBAC, audit trails)
Define dashboards/metrics for auto-adjudication rate, first-pass yield, claim touch rate, cycle time, payment accuracy, denial trends, throughput, and operational leakage
Collaborate with Data Engineering on pipelines, reconciliations, exception management, and root-cause analysis
Serve as day-to-day product lead for Claims, Operations, Compliance, Client Services, and external vendors/clearinghouses
Coordinate ceremonies and delivery across offshore/onshore teams; manage SLAs and integration timelines
Lead discovery to simplify workflows and increase automation; improve UX for adjusters, billing teams, and provider/client interfaces
Maintain a living configuration playbook (plan/benefit setup, pricing rules, enrollment tie-ins) to reduce errors and accelerate onboarding
Qualification
Required
5-7+ years of product management or solutions leadership in healthcare payer / TPA / MSO environments with ownership of claims platforms
Practical experience with EDI/X12 (837/835/270/271/276/277/278), claim adjudication rules, benefit configuration, and clearinghouse integrations
Proven ability to translate business/regulatory needs into product specs and deliver iterative releases with engineering teams
Strong grounding in HIPAA, data privacy/security, and audit/compliance practices
Preferred
Exposure to Medicare Advantage operations and CMS timelines; familiarity with NCQA programs and utilization management workflows
Technical fluency with Azure, .NET/C#, Python, SQL, and tools like Azure DevOps/Jira/Confluence; Power BI/Tableau
Working knowledge of ICD-10, CPT/HCPCS, DRG/APC, provider contracting/pricing, COB/TPL, and prior authorization workflows
Experience delivering with offshore development teams across time zones
Benefits
Discretionary bonuses
Medical, dental, and vision benefits
401(k) retirement plan
Company
Vaco by Highspring
Vaco is the Talent Solutions division of Highspring, a leading global professional services organization.
5001-10000 employees
H1B Sponsorship
Vaco by Highspring has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2023 (1)
Funding
Current Stage
Late StageCompany data provided by crunchbase