Operations Manager- Member Experience

Job Description
Position summary

The Operations Manager, Member Experience supports the overall operations of VIVIO's Member Experience organization and issue resolution and quality. In this client-facing role, the manager works directly with clients, consultants and vendors on member-facing issues, owning each from first notice to final resolution:

We are looking for a strong root cause analyst who looks past individual complaints to find and fix the underlying process, system, policy or training gap. Member issue resolution, quality and AI tool oversight are the core focus, but the role supports Member Experience operations wherever the business needs it as VIVIO grows.

Key responsibilities

Client, Consultant and Vendor Partnership

Serve as a primary point of contact for clients, consultants and vendors on member-facing issues, owning communication from intake to resolution with clear, proactive updates.
Lead issue review calls and deliver written resolution summaries covering timeline, member impact, root cause, corrective actions and follow-up commitments.
Handle difficult conversations with composure and empathy, balancing partner expectations with contract terms, regulatory requirements and operational realities.
Build trusted relationships and present issue trends, quality results and improvements in client and consultant business reviews.

Member Issue Resolution and Escalations

Prioritize member-facing issues by urgency and impact to minimize medication delays, and serve as the final internal escalation point for complex member, pharmacy, prescriber and payer issues.
Coordinate with providers, pharmacies, vendors and internal teams to resolve cases and confirm the member outcome before closure.
Maintain intake, triage, SLA and documentation standards, and streamline workflows that delay medication fills or other member services.
Track KPIs (volume, time to resolution, SLA adherence, repeat issues, satisfaction) and audit case handling to drive improvement plans.

Root Cause Analysis and Continuous Improvement

Lead structured root cause analysis on issues, escalations, complaints, quality failures and incidents using methods such as 5 Whys, fishbone diagrams, Pareto analysis and process mapping.
Separate symptoms from underlying causes (process, system, data, policy, vendor or training) and validate findings with data.
Own corrective and preventive action (CAPA) plans with clear owners, deadlines and success measures, and confirm fixes are sustained.
Analyze trends to catch recurring failure points and emerging risks early, and partner with cross-functional teams to fix problems at the source.

Quality and Compliance

Lead the quality program, including call and case audits, scorecards, evaluator calibration and timely, constructive feedback.
Ensure adherence to policies, client and payer contracts, HIPAA and healthcare regulations; support internal, external and client audits.
Turn quality findings into root cause inputs, training recommendations, job aids and updated SOPs.

AI Tool Oversight

Serve as the team's expert on VIVIO's AI tool and coach staff on using it well.
Review AI-assisted interactions for accuracy and compliance, partner with technology to improve the tool, and identify automation opportunities that reduce repeat issues and strengthen quality.
Leadership, Reporting and Collaboration

Coach and develop team leads and staff; manage schedules, goals and performance reviews, and build a culture of ownership and member-first service.
Report issue, escalation, quality and root cause trends to leadership with data-driven insights and progress on corrective actions.

Qualifications
Required

3+ years in member experience, PBM, pharmacy claims or related healthcare operations.
2+ years managing teams in a queue-based or contact center environment, including escalations or quality assurance.
Client-facing experience resolving member-facing issues directly with clients, consultants or vendors and communicating resolution and root cause.
Proven root cause analysis experience, with concrete examples of sustainable corrective actions.
Knowledge of prior authorization, coordination of benefits, pharmacy claim rejections and HIPAA.
Proficiency with CRM or claims systems and Excel (including pivot tables); high school diploma or equivalent.
Preferred

Bachelor's degree in healthcare administration, business or a related field.
Specialty pharmacy, mail order or long-term care experience.
Experience presenting to clients or executives

Skills and competencies

Client presence: a polished, composed communicator who explains complex issues simply and earns partner trust.
Root cause analysis: curious and analytical; asks why until the real cause is found and backs it with data.
Ownership and follow-through: sees every issue and corrective action through to a verified fix.
Operational judgment: prioritizes well and makes sound decisions under pressure.
Leadership and coaching: develops people and builds accountable teams.
Adaptability: ready to take on new areas of Member Experience as the business evolves.