Health Plan and Operations Manager

@ Asian Health Services

Asian Health Servicesasianhealthservices.com

Health Plan and Operations Manager

Posted 3 months ago

This job is still taking applications, but it's been up a while.

About the job

Asian Health Services builds culturally competent care for seniors, integrating medical, transportation, meals, social activities, and support systems for the elderly.

Requirements

3+ years managed care experience
Knowledge of Medi-Cal/Medicare
Claims, enrollment, provider operations
Familiar with CMS/DHCS rules

Qualifications

Bachelor's in Healthcare or related
Experience with managed care workflows
Strong communication skills
Attention to detail and multitasking

Full job description

Imagine a center where our seniors can receive transformative health care that will allow them to age at home and in their communities.

At Asian Health Services, we recognize that so many of our elderly patients continue to struggle to get the care they need because of challenges that go beyond the walls of the clinic.

To address these gaps, we’ve found a solution and model of care that integrates the quality care our elders receive at our health center with the most comprehensive support system, like transportation, culturally-inclusive meals, and social activities, our elders deserve.

We are building a Program of All-Inclusive Care for the Elderly (PACE) to bring life-changing, culturally competent care to low-income seniors—supporting them as they age safely and with dignity, right in their communities. Based on the PACE model, SpringLight Health will offer coordinated medical care, transportation, meals, social activities, medication management, and caregiver support—all tailored to each individual’s needs.

Learn more by visiting our website here.

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 Functions

Health 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

Benefits That Support You
We're committed to supporting our team's well-being. Our comprehensive benefits package includes:

Health & Wellness

100% employer-paid Medical, Dental & Vision coverage
Acupuncture & Chiropractic coverage

Time Off

12 vacation days
12 sick days
12 paid holidays + 3 floating holidays (additional flexible days you can use anytime)

Financial & Retirement

403(b) with 3% employer contribution + up to 2% match
Flexible Spending Account (FSA) & Dependent Care Assistance

Additional Support

Commuter benefits
Long-Term Disability Insurance

Please note: We are not seeking support from staffing agencies at this time. Direct applicants only.

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