Senior Manager, Operations - Applications and Analytics

Come Grow With Us
At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.

Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person - health, health care, and social services and supports - are met. We are seeking collaborators, innovators, and those who are driven to be their very best.

If you are looking for a career of purpose and are passionate about having an impact on society's health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure.

About this role:

POSITION SUMMARY
The Senior Manager, Operations - Applications and Analytics has responsibility for providing leadership and management in the areas of claims-related services, including processing, auditing, research, and resolution, reporting and process improvement. This position will be responsible for the coordination of Gold Coast Health Plan's (GCHP"s) outsourced claims processing transaction functions as well as the overall daily management of GCHP"s internal Claims and Analytics team. The internal Claims and Analytics team's primary focus is on claims and operational analysis, research, projects, auditing, high dollar claims approval, partnering with the G&A department with Provider Disputes and supporting all other GCHP departments, while transaction processing and adjustments is performed by GCHP's vendor. The Sr. Manager of Operations, Claims will ensure that the claims payment process adheres to regulatory requirements, that payments are made according to benefit and contract terms, and that providers have a high level of satisfaction with claims payment performance. The Manager reports directly to the Executive Director of Operations and partners with other departmental managers and external vendors on all strategic and tactical matters as they relate to provider claims and payments.

In addition the candidate will have responsibility for providing leadership and management across a broad set of operational services, including transaction oversight, auditing, research, reporting, and process improvement. This position is responsible for the coordination of Gold Coast Health Plan's (GCHP's) outsourced operational transaction functions as well as the overall daily management of internal Operations and Analytics teams.

The internal Operations and Analytics team's primary focus is on operational analysis, research, projects, auditing, approval workflows, partnering with other administrative departments on operational issues, and supporting all other GCHP departments. The Senior Manager, Operations - Applications and Analytics will ensure that operational processes adhere to regulatory requirements, that activities are executed according to policy, contract, and system rules, and that internal and external stakeholders experience a high level of service

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
Job Function & Responsibilities
* Lead and direct the claims management process, driving execution of best practices and related initiatives designed to provide a high level of efficiency and accuracy.
* Ensure the processing of claims payments adheres to regulatory requirements and that payments are made according to benefit and contract terms; work to minimize the volume of pended and adjusted claims
* Ensure effective and efficient operational processes and regulation adherence including validation that all new policies and procedures are implemented
* Provide subject matter expertise in project management and other areas of expertise
* Lead, coordinate and complete operational improvement projects across various functional areas within and outside of Gold Coast Health Plan
* Own end-to-end process improvement: including definition of need, project plans, status updates, reporting and achieving results
* Establish operating metrics and daily, weekly, and monthly scorecards to manage ongoing operations
* Enhance the operational procedures, systems, and principles in the areas of information flow and management, business processes, enhanced management reporting and identification of process improvements
* Develop collaborative relationships with and confirms business partners can execute day-to-day responsibility for operations
* Develop collaborative relationships with matrixed partners and vendors
* Inform and advise management regarding California Department of Health Care Services' current trends, problems and activities to facilitate both short- and long-range strategic plans to improve operational performance
* Own operational accountability for the successful system conversions, where applicable
* Identify and resolve technical, operational, and organizational problems inside and outside health plan
* Lead teams to resolve business problems that affect multiple functions or disciplines
* Lead and influence staff by fostering teamwork and collaboration, driving employee engagement, and leveraging diversity and inclusion
* Drive high-quality execution and operational excellence by communicating clear directions and expectations
* Review and approve workflows, business processes, and business requirements documentation for all claims related functions and projects, ensuring that all documentation is complete and accurate
* Monitor and provide oversight to delegated entities with regard to claims compliance from a regulatory and contractual perspective
* Enhance the operational procedures, systems, and principles in the areas of information flow and management, business processes and management reporting
* Prepare requested materials for internal and external regulatory audits and legal requests
* Address escalating claims issues from providers and members to facilitate resolution of problems in an accurate, timely, professional, and courteous manner
* Manage, select, evaluate, train, lead and direct staff in support of strategic and business efforts; build an effective team and ensure appropriate staffing and staff development
* Effectively translates strategic goals into specific operating and resource plans
* Coordinate and supervise operational analyses and implementation support on major workflow and claim system modification.
* Act as a consultant for senior management, related to reimbursement methodologies, regulatory requirements, and claims processing protocols
* Work with recovery vendor to identify funds paid in error, recovery of those funds including reporting of outstanding balances and funds recovered
* Lead teams to resolve business problems that affect multiple functions or disciplines
* Manage and develop the annual budget for the claims department
* Partner with leadership to maintain external contact with regulatory agencies, providers, delegated entities, community-based organizations, and other health plans in all issues relative to grievances and appeals
* Knowledge of:
o Principles and practices of health care service delivery and managed care, Medi-Cal eligibility, and benefits. Medical billing/coding (CPT, HCPCS, ICD-9 and ICD-10); COB/TPL regulations and guidelines.
o Claims operations and supporting information systems; experience in developing and tracking performance metrics.
o Principles, practices, techniques, and theories of claims administration and customer service for a government agency serving a diverse social and ethnic population.
o State and federal regulations as they relate to Medi-Cal managed care and other related business and policies governing managed care issues.
* Perform such other duties as assigned.

MINIMUM QUALIFICATIONS
Education & Experience:
* High School Graduate or General Education Degree (GED)
* 8 plus years of experience in professional-level experience in a claims processing department as a manager; Preferably in a Medi-Cal/Medicaid managed care plan
* Excellent understanding of claims regulatory requirements including but not limited to AB1455, AB97, COB and clinical editing (NCCI)

KNOWLEDGE, SKILLS & ABILITIES
Preferred Qualifications:
* Bachelor's Degree (four-year college or technical school)
* Prior experience with Meditrac claims processing system
* Prior experience with Optum CES and Easy Group
* Prior experience with MHK
* Excellent analytical ability, judgment and problem solving.
* Ability to present complex information in an understandable and compelling manner.
* Evaluate, understand, and interpret policies, procedures and regulations; develop/revise policies and procedures as required.
* Develop and implement operational and service level goals.
* Remain knowledgeable of the health plan's benefit structure.
* Manage projects and prioritize the resources to optimize the use of those resources to maximize effectiveness.
* Effectively present complex information to diverse audiences.
* Develop constructive and cooperative working relationships with others.
* Select, motivate, and evaluate staff, and provide for their training and professional development.
* Work in a fast paced, diverse organization that is performance oriented.
* Prepare clear and concise reports, correspondence, and other written materials. Maintain confidentiality regarding sensitive information.

Computer Skills: Advanced computer skills included in the MS Office products including Access.

Certifications & Licenses: A valid and current Driver's License, Auto Insurance, and professional licensure(s)

Competency Statements
* Management Skills - Ability to organize and direct oneself and effectively supervise others.
* Business Acumen - Ability to grasp and understand business concepts and issues.
* Decision Making - Ability to make critical decisions while following company procedures.
* Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.
* Interpersonal - Ability to get along well with a variety of personalities and individuals.
* Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.
* Time Management - Ability to utilize the available time to organize and complete work within given deadlines.
* Consensus Building - Ability to bring about group solidarity to achieve a goal.
* Relationship Building - Ability to effectively build relationships with customers and co-workers.
* Presentation Skills - Ability to effectively present information publicly.
* Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.
* Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.
* Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.
* Judgment - The ability to formulate a sound decision using the available information.
* Communication, Oral - Ability to communicate effectively with others using the spoken word.
* Communication, Written - Ability to communicate in writing clearly and concisely.
* Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.

PHYSICAL DEMANDS
O (Occasionally) Position requires this activity up to 33% of the time (0 - 2.5+ hrs/day)
F (Frequently) Position requires this activity from 33% - 66% of the time (2.5 - 5.5+ hrs/day)
C (Constantly) Position requires this activity more than 66% of the time (5.5+ hrs/day)

Stand O
Walk F
Sit C
Manually Manipulate C
Reach Outward O
Grasp F
Lift 10 -20lbs O
Carry 10-20lbs O

WORK ENVIRONMENT
Office work environment.

The estimated pay range for the position is:

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 and future increases will be based on the pay band for the city and state you reside in.