Health Plan and Operations Manager

{
  "content_hash": "7f7fe89a8b0ff6e78d891974f2e74486d7580af74d65e3025817bf71c9371b9f",
  "source_hash": "90e8fc88043617152ece28b40b331fad5e820c1dcfd3b5a1cc0257f8a63e2c4f",
  "last_changed_at": "2026-06-17T07:56:34.173Z",
  "active_status": "active"
}

{
  "language": "en",
  "location": {
    "raw": "San Leandro, CA",
    "city": "San Leandro",
    "region": "CA",
    "country": "United States",
    "is_remote": false,
    "confidence": 0.9
  },
  "salary_max": 138000,
  "salary_min": 115000,
  "inferred_at": "2026-06-18T07:56:03.653Z",
  "launch_scope": {
    "reason": "english_us_canada",
    "included": true,
    "language": "en",
    "location": {
      "raw": "San Leandro, CA",
      "city": "San Leandro",
      "region": "CA",
      "country": "United States",
      "is_remote": false,
      "confidence": 0.9
    },
    "countries": [
      "United States"
    ]
  },
  "remote_policy": "hybrid",
  "salary_period": "year",
  "workplace_type": "hybrid",
  "salary_currency": "USD"
}

{}

{
  "lists": [
    {
      "text": "Essential Job Functions",
      "content": "<div>\n<p><strong>Health Plan Administration</strong></p>\n\n<li>Support day-to-day health plan administration functions across claims, enrollment, provider operations, and care coordination workflows</li>\n<li>Assist in developing and maintaining SOPs, escalation pathways, and performance tracking processes</li>\n<li>Monitor operational workflows and flag issues for timely resolution</li>\n\n<p><strong>Claims, Encounter &amp; Vendor Coordination</strong></p>\n\n<li>Coordinate with delegated TPA and vendor partners on claims adjudication and payment workflows</li>\n<li>Track pended and paid claims and support operational issue resolution</li>\n<li>Assist in ensuring accurate and timely encounter data submission to DHCS and CMS</li>\n<li>Support reconciliation and reporting activities related to encounter submissions, enrollment, and risk scores</li>\n<li>Coordinate with Finance on claims reconciliation and operational financial reporting</li>\n\n<p><strong>Enrollment &amp; Eligibility Operations</strong></p>\n\n<li>Manage participant enrollment and disenrollment workflows, including CMS and DHCS submission tracking</li>\n<li>Support Medi-Cal and Medicare eligibility verification and redetermination processes</li>\n<li>Identify and escalate enrollment-related issues to ensure eligibility continuity for participants</li>\n\n<p><strong>Provider Network &amp; Relations</strong></p>\n\n<li>Support provider network operations including provider data maintenance, credentialing coordination, and access management</li>\n<li>Serve as an operational point of contact for provider relations, issue resolution, and escalation workflows</li>\n<li>Monitor network adequacy and service level concerns, escalating as appropriate</li>\n\n<p><strong>Pharmacy &amp; Part D Support</strong></p>\n\n<li>Coordinate day-to-day pharmacy operations and support PBM relationship management</li>\n<li>Assist with formulary administration activities and pharmacy vendor performance monitoring</li>\n<li>Support operational preparation for annual Part D bid processes alongside Finance and external consultants</li>\n\n<p><strong>Care Coordination &amp; Referral Operations</strong></p>\n\n<li>Coordinate centralized referral workflows and external appointment scheduling processes</li>\n<li>Ensure timely specialty scheduling, visit note retrieval, and participant follow-through</li>\n<li>Collaborate with Clinical Operations and IDT teams on care transitions and participant access issues</li>\n\n<p><strong>Regulatory &amp; Compliance Support</strong></p>\n\n<li>Support operational readiness activities for CMS and DHCS requirements</li>\n<li>Maintain SOPs, operational documentation, and reporting processes in an audit-ready state</li>\n<li>Assist with audit preparation and delegated oversight coordination</li>\n\n<p><strong>Cross-Functional Coordination</strong></p>\n\n<li>Partner with Finance, Compliance, Quality, and Clinical Operations on shared workflows and escalations</li>\n<li>Support DHCS/CMS operational requests and reporting activities</li>\n<li>Communicate participant access barriers and operational gaps to appropriate stakeholders</li>\n\n<p><strong>Team &amp; Operational Support</strong></p>\n\n<li>May oversee one or more operational staff or coordinators as the team grows</li>\n<li>Contribute to workforce and process improvement initiatives as census scales</li>\n\n</div>"
    },
    {
      "text": "Minimum Qualifications",
      "content": "<div>\n\n<li>Bachelor's degree in Business, Accounting, Finance, Healthcare Administration, or related field</li>\n<li>3+ years of managed care, health plan, IPA, MSO, or PACE operational experience</li>\n<li>Working knowledge of Medi-Cal, Medicare, and/or dual-eligible populations</li>\n<li>Experience with claims, enrollment, provider operations, or delegated vendor coordination</li>\n<li>Familiarity with CMS and DHCS regulatory requirements</li>\n<li>Comfort operating in evolving, build-as-you-go environments preferred</li>\n\n</div>"
    },
    {
      "text": "Preferred Qualifications",
      "content": "<div>\n\n<li>Master's degree in Business Administration (MBA), Health Administration (MHA), or related field</li>\n<li>Supervisory or lead experience in health plan operations</li>\n<li>Experience in a startup or high-growth healthcare environment</li>\n<li>Strong attention to detail and follow-through</li>\n<li>Ability to manage multiple workflows and competing priorities</li>\n<li>Clear, collaborative communication across teams</li>\n<li>Comfort with ambiguity and a continuous improvement mindset</li>\n<li>Analytical and process-oriented approach to problem-solving</li>\n\n</div>"
    }
  ],
  "country": "US",
  "createdAt": 1776791363529,
  "updatedAt": null,
  "categories": {
    "team": "SpringLight PACE",
    "location": "San Leandro, CA",
    "commitment": "Full-time",
    "department": "Clinical & Program Services",
    "allLocations": [
      "San Leandro, CA"
    ]
  },
  "salaryRange": {
    "max": 138000,
    "min": 115000,
    "currency": "USD",
    "interval": "per-year-salary"
  },
  "workplaceType": "hybrid"
}