Job Location: California

Salary: $80,000-$82,000

Position Summary:

The Operations Manager will serve as the operational owner of the Pear Suite billing and claims workflow for CalAIM Community Supports. This role is responsible for managing the full claims lifecycle from claim generation through submission, adjudication, reconciliation, denial management, and closure, ensuring that services provided are billed accurately, timely, and in compliance with payer and regulatory requirements. This position works closely with Data, Finance, Program, Compliance, and external billing vendors. The Operations Manager plays a critical role in safeguarding revenue, supporting audits, improving processes, and preparing the organization for expansion into additional counties and health plans.

Position Responsibilities

Claims & Billing Operations

• Serve as the day-to-day operational owner of Pear Suite or similar for CalAIM Community Supports billing.
• Manage and oversee the end-to-end claims lifecycle, from generation through screening, approval, submission, and final resolution.
• Ensure claims are reviewed, approved, and submitted according to internal/Funder/DHCS- QC standards and payer timelines.
• Monitor claim statuses and system dashboards to identify risks, delays, or systemic issues.
• Monitor and enforce CalAIM billing timeliness requirements, including retroactive billing windows and corrected claim resubmission deadlines.
• Oversee processes for PMPM billing logic and expected denial patterns to ensure accurate and compliant billing outcomes..
• Support monitoring of service-specific lifetime caps (e.g., housing deposits, environmental accessibility adaptations).
• Coordinate with program and compliance stakeholders when caps or billing limits are nearing or have been reached to ensure appropriate action.

Claims & Billing Management

• Lead denial, rejection, and correction management processes, including review of ERA feedback and denial reason codes.
• Determine appropriate paths (corrective action versus claim closure) and ensure corrected claims are reissued within resubmission limits.
• Track and analyze denial and rejection trends; escalate issues that indicate upstream data, workflow, or system configuration gaps.
• Manage denial and correction logs, ensuring complete documentation to support audits, reporting, and continuous improvement.

Process Improvement & Expansion

• Identify and implement opportunities to improve billing workflows and improve efficiency to ensure clean claim rates.
• Ensure compliance and quality control by contributing to the refinement of SOPs, job aids, and internal controls, and ensuring billing processes align with CalAIM, DHCS, health plan, and contractual requirements.
• Support the onboarding of new regions, payers, and Community Supports as CalAIM expands.

Requirements

Professional Experience

• At least 2 years of experience in billing, claims, or revenue cycle management, preferably in healthcare, Medicaid, or public sector programs.
• Preferred experience managing claims workflows and payer rules, including denials and corrections.

• Experience working with billing and claims technology platforms (e.g., Pear Suite, clearinghouses, or comparable systems).

• Experience supporting audits and compliance reviews strongly preferred.

• A minimum of 3 years working in a social justice, human services, non-profit management, healthcare, or public policy agency.
• At least two years of experience building and managing teams, experience overseeing contracts, budgets, and invoicing processes.

• Demonstrated leadership as evidenced by increasing levels of responsibility and management over the course of the candidate's career.

Knowledge, Skills and Abilities

• Familiarity with accounting principles, government contracting, and business process optimization.
• Demonstrated ability in leveraging data to drive strategic decision-making and system improvements.
• Strategic and systems-oriented leader with the ability to design, implement, and sustain inclusive and transparent decision-making frameworks.
• Strong communication, critical thinking, and independent judgment skills, with a creative and solution-oriented mindset.
• Highly organized with strong project management, planning, and prioritization abilities, able to perform effectively under pressure and refine systems with a holistic, "big picture" perspective..
• Effective communicator with the ability to lead, influence, and collaborate across diverse and cross-cultural environments using an equity-centered approach.
• Proficiency with MS Outlook, Word, PowerPoint and Excel required; experience with databases such as Salesforce preferred.
• Intacct software experience preferred but not required

Core Competencies

• Strategic Agility: Future-oriented, strategically coordinates resources and stakeholders to optimize support, proactively navigating challenges through planning and critical thinking
• Process Management: Excels at developing and organizing efficient workflows, measuring key aspects, and simplifying complex processes to maximize resource utilization
• Building Effective Teams: Builds cohesive, high-performing teams through collaboration, positive culture, coaching, cross-functional work, and recognition of successes
• Functional/Technical Expertise: Possesses advanced functional/technical skills of direct reports, enabling high-level task accomplishment, optimal partner support, and team development

Physical Requirements

Candidates should have physical mobility for tasks such as standing, bending, stooping, kneeling, crouching, reaching, twisting, and walking on uneven surfaces. They should be capable of performing stationary tasks like sitting for up to 6 to 8 hours a day. Additionally, candidates should be able to lift, carry, push, pull light to moderate weights up to 15 pounds safely. Requires mental acuity for analytical reasoning and document interpretation.

Salary range for this position is $80,000- $82,000 annually. This position is being offered at $80,000-$82,000 annually.

Benefits

Benefits

• Health Care Plan (Medical, Dental, & Vision)
• Retirement Plan (With 5% Match)
• Life Insurance (Basic, Voluntary and AD&D)
• Paid Time Off (Vacation, Sick & Public Holidays)
• Family Leave (Maternity, Paternity)
• Short Term & Long-Term Disability
• Training & Development
• Wellness Resources
• Hybrid Work