Manager, Operations

Gold Coast Health Plan will not sponsor applicants for work visas.

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California.

POSITION SUMMARY

Under the direction of the Director of Operations, the Operations Manager, is responsible for coordination and oversight of operational activities. This includes supervising the day-to-day activities and performance of assigned staff, carrying out department goals and objectives, measurements of performance, collaboration with other departments, adherence to policies and procedures, and ensuring performance and work product quality standards are met, and any other duties assigned. 

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statements

•    Must have the ability to work and manage cross functional department, i.e. Grievance & Appeals, Change Management and Claims Oversight. 

•    Review, prioritize and analyze internal and external reporting for evaluation of delegates performance. 

•    Evaluation requiring an in-depth understanding of appropriate payment or denial practices, benefits, policies and procedures, and contract interpretation.

•    Research and define configuration and programming specifications for new or updated business requirements including benefits, pricing, and authorizations to address noncompliance with delegates contractual obligations.

•    Work on escalated issues from internal staff that requires extensive research and resolution.

•    Supervises the day-to-day activities and performance of assigned staff with duties including but not limited to:

•    Supervising assigned staff

•    Interviewing and participating in the selection of qualified candidates

•    Completing staff performance evaluations in a timely manner

•    Issuing work assignments to include cross-training with other staff

•    Identifying errors and deficiencies and developing and implementing corrective action and training plans for staff

•    Assisting in developing the training curriculum for supervised staff and providing staff development opportunities through project assignments, instruction, and feedback

•    Assisting staff with time management including monitoring time and attendance, approving time off requests, reviewing, and approving timecards and ensuring proper staffing during absences

•    Ensuring that business goals, deadlines and performance standards are met 

•    Setting goals for staff and making sure they comply with the company’s plans and vision 

•    Implements and enforces systems, policies, and procedures

•    Ability to effectively organize and manage multiple company initiatives simultaneously

•    Carries out department goals and objectives, measurements of performance, policies, and procedures and ensures performance and work product quality standards are met with duties including but not limited to

•    Monitoring, supporting, and assuring efficient and accurate performance of the claims processing operation, including proper administration of benefit and payment rules (Adjudication), appropriate provider communication via phone and written correspondence and accurate configuration of the claims processing system (Systems)

•    Supervising and planning department functions to meet short- and long-term department goals and objectives including the promotion of teamwork and collaborative efforts among staff

•    Preparing and reviewing quality control audits with staff to ensure compliance within established department guidelines, goals, policies, and procedures

•    In partnership with delegates and internal departments, prioritize and provide reporting related to performance and system change requests.

•    Management and monitoring of corrective action plans and service level agreements. 

•    Producing policy and procedure instructions for the operations staff which includes development, implementation, and interpretation of policy and procedures for the Operations Department

•    Performing analysis and developing improvements to the operation

•    Producing and maintaining statistics of production and inventory for Senior Manager of Operations on a daily, weekly, and monthly basis

•    Collaborating with all other departments as needed to resolve related issues and assist in policy planning and implementation

•    Act as a liaison between delegates and internal departments

•    Maintaining current knowledge of GCHP policy and procedure, Medi-Cal, Provider Manuals, Knox Keene, State and Title XXII regulations

•    Leading or participating in special projects and assignments as needed

•    Any other duties assigned

POSITION QUALIFICATIONS

Competency Statements

•    Business Acumen - Ability to grasp and understand business concepts and issues.

•    Communication, Oral - Ability to communicate effectively with others using the spoken word.

•    Communication, Written - Ability to communicate in writing clearly and concisely.

•    Research Skills - Ability to design and conduct a systematic, objective, and critical investigation.

•    Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

SKILLS & ABILITIES

Education:

•    High School Graduate or General Education Degree (GED): Required

•    Bachelor Degree, preferred

Experience:    

•    Minimum of five years in a managed care healthcare environment 

•    Three plus years’ experience with Medi-Cal guidelines 

•    Three plus years’ experience data analytics and reporting 

•    Two years’ experience in a Supervisor, Lead, Trainer, Quality Assurance or Auditor role highly preferred.

•    Three years’ experience using analytical thinking skills and demonstrated ability to exercise sound judgment when making decisions

Computer Skills:    Computer proficiency included in the MS Office programs.

Certifications & Licenses: A current and valid California Driver's License and Insurance.

Other Requirements:    

Knowledge of:

•    Medi-Cal eligibility and benefits.

•    Medical billing/coding (CPT, HCPCS, ICD-9/ICD-10); COB/TPL regulations and guidelines

•    All claim types and standard claims adjudication practices.

•    Provider reimbursement methodologies.

•    Claim processing functions

•    Medical terminology, related procedures and diagnostic coding, and knowledge of how to access available resource tools

•    MS Word, Excel and Outlook required

•    Medi-Cal regulations; working knowledge of Medicare (CMS), and commercial (DMHC). Also requires knowledge of health plan division of financial responsibility (DOFR), and industry “best practices.”

Ability to:

•    Coordinate, delegate and supervise the work of others

•    Maintain accurate records

•    Train staff on function of claims operations

•    Exercise diplomacy and tact.