Health Plan and Operations Manager
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 YouWe'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.