Health Plan and Operations Manager
Asian Health ServicesAbout the role
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.
Essential Job Functions
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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 ap
Health Plan Administration
Claims, Encounter & Vendor Coordination
Enrollment & Eligibility Operations
Provider Network & Relations
Pharmacy & Part D Support
Care Coordination & Referral Operations
Regulatory & Compliance Support
Cross-Functional Coordination
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