Product Manager, TPA/Claims Processing

$120,000-130,000 DOE 

100% remote in the US only, EST or CST states preferred 

Role Summary

A rapidly growing healthcare organization is seeking a Product Manager to own the strategy, roadmap, and delivery of its Claims Processing Platform—the core system supporting accuracy, speed, and regulatory compliance across Third-Party Administrator (TPA)/ Managed Services Organization (MSO) operations.

This role serves as the critical link between business stakeholders and engineering, translating operational goals and regulatory requirements into clear product outcomes, detailed user stories, and actionable deliverables for a distributed development team (offshore + onshore). Success will be measured through improvements in auto-adjudication, first-pass yield, payment accuracy, cycle time, and cost-to-serve.

The ideal candidate brings hands-on experience with professional/institutional/pharmacy claims, EDI/X12, payer/TPA workflows, and healthcare compliance (HIPAA/CMS), and is equally comfortable running discovery with Claims Ops leaders and collaborating daily with engineers through delivery.

---

What You’ll Do

1) Product Strategy & Roadmap

• 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.

2) Business–IT Translation

• 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.

3) Claims Domain Ownership

• 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).

4) Delivery & Quality

• 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.

5) Regulatory & Compliance

• Ensure adherence to HIPAA/HITECH, CMS guidance (including Medicare Advantage considerations), ERISA/state requirements, and internal security controls (RBAC, audit trails).

6) Data & Analytics

• 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.

7) Stakeholder & Vendor Coordination

• 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.

8) Continuous Improvement

• 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.

---

Minimum Qualifications

• 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 Skills

• 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.

Determining compensation for this role (and others) at Vaco/Highspring depends upon a wide array of factors including but not limited to the individual’s skill sets, experience and training, licensure and certifications, office location and other geographic considerations, as well as other business and organizational needs. With that said, as required by local law in geographies that require salary range disclosure, Vaco/Highspring notes the salary range for the role is noted in this job posting. The individual may also be eligible for discretionary bonuses, and can participate in medical, dental, and vision benefits as well as the company’s 401(k) retirement plan. Additional disclaimer: Unless otherwise noted in the job description, the position Vaco/Highspring is filing for is occupied. Please note, however, that Vaco/Highspring is regularly asked to provide talent to other organizations. By submitting to this position, you are agreeing to be included in our talent pool for future hiring for similarly qualified positions. Submissions to this position are subject to the use of AI to perform preliminary candidate screenings, focused on ensuring minimum job requirements noted in the position are satisfied. Further assessment of candidates beyond this initial phase within Vaco/Highspring will be otherwise assessed by recruiters and hiring managers. Vaco/Highspring does not have knowledge of the tools used by its clients in making final hiring decisions and cannot opine on their use of AI products.