Job Summary: This role presents an exciting opportunity for a detail-oriented, operationally strong professional to support the build-out and day-to-day functioning of health plan operations for a new PACE program. The Manager will be responsible for executing and coordinating key operational workflows across claims, enrollment, provider relations, pharmacy support, and care coordination, working closely with senior leadership to ensure compliance, vendor performance, and participant-centered service delivery.
Essential Job FunctionsHealth Plan Administration- Support day-to-day health plan administration functions across claims, enrollment, provider operations, and care coordination workflows
- Assist in developing and maintaining SOPs, escalation pathways, and performance tracking processes
- Monitor operational workflows and flag issues for timely resolution
Claims, Encounter & Vendor Coordination- Coordinate with delegated TPA and vendor partners on claims adjudication and payment workflows
- Track pended and paid claims and support operational issue resolution
- Assist in ensuring accurate and timely encounter data submission to DHCS and CMS
- Support reconciliation and reporting activities related to encounter submissions, enrollment, and risk scores
- Coordinate with Finance on claims reconciliation and operational financial reporting
Enrollment & Eligibility Operations- Manage participant enrollment and disenrollment workflows, including CMS and DHCS submission tracking
- Support Medi-Cal and Medicare eligibility verification and redetermination processes
- Identify and escalate enrollment-related issues to ensure eligibility continuity for participants
Provider Network & Relations- Support provider network operations including provider data maintenance, credentialing coordination, and access management
- Serve as an operational point of contact for provider relations, issue resolution, and escalation workflows
- Monitor network adequacy and service level concerns, escalating as appropriate
Pharmacy & Part D Support- Coordinate day-to-day pharmacy operations and support PBM relationship management
- Assist with formulary administration activities and pharmacy vendor performance monitoring
- Support operational preparation for annual Part D bid processes alongside Finance and external consultants
Care Coordination & Referral Operations- Coordinate centralized referral workflows and external appointment scheduling processes
- Ensure timely specialty scheduling, visit note retrieval, and participant follow-through
- Collaborate with Clinical Operations and IDT teams on care transitions and participant access issues
Regulatory & Compliance Support- Support operational readiness activities for CMS and DHCS requirements
- Maintain SOPs, operational documentation, and reporting processes in an audit-ready state
- Assist with audit preparation and delegated oversight coordination
Cross-Functional Coordination- Partner with Finance, Compliance, Quality, and Clinical Operations on shared workflows and escalations
- Support DHCS/CMS operational requests and reporting activities
- Communicate participant access barriers and operational gaps to appropriate stakeholders
Team & Operational Support- May oversee one or more operational staff or coordinators as the team grows
- Contribute to workforce and process improvement initiatives as census scales
Minimum Qualifications- Bachelor's degree in Business, Accounting, Finance, Healthcare Administration, or related field
- 3+ years of managed care, health plan, IPA, MSO, or PACE operational experience
- Working knowledge of Medi-Cal, Medicare, and/or dual-eligible populations
- Experience with claims, enrollment, provider operations, or delegated vendor coordination
- Familiarity with CMS and DHCS regulatory requirements
- Comfort operating in evolving, build-as-you-go environments preferred
Preferred Qualifications- Master's degree in Business Administration (MBA), Health Administration (MHA), or related field
- Supervisory or lead experience in health plan operations
- Experience in a startup or high-growth healthcare environment
- Strong attention to detail and follow-through
- Ability to manage multiple workflows and competing priorities
- Clear, collaborative communication across teams
- Comfort with ambiguity and a continuous improvement mindset
- Analytical and process-oriented approach to problem-solving
$115,000 - $138,000 a year
Note: 1.0 FTE equals 40 hours per week.
