Senior Manager, Operations - Applications & Analytics

Senior Manager, Operations - Applications & Analytics

Gold Coast Health Plan invites you to apply for the Senior Manager, Operations - Applications & Analytics position. Direct message the job poster from Gold Coast Health Plan.

The Senior Manager, Operations
- Applications and Analytics leads claims-related services, including processing, auditing, research, resolution, reporting, and continuous process improvement. Responsible for coordinating outsourced claims processing and managing the internal Claims and Analytics team, ensuring regulatory compliance, accurate payments, and provider satisfaction. Reports to the Executive Director of Operations and partners with departmental managers and vendors.

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

• Lead and direct the claims management process, driving execution of best practices and related initiatives.
• Ensure claims payment processing adheres to regulations and contract terms; minimize pended and adjusted claims.
• Ensure operational processes and regulation adherence, validating all new policies and procedures.
• Provide subject‑matter expertise in project management and related areas.
• Lead, coordinate, and complete operational improvement projects across functional areas inside and outside the plan.
• Own end‑to‑end process improvement: definition, project plans, status updates, reporting, and results.
• Establish operating metrics and scorecards to manage ongoing operations.
• Enhance procedures, systems, and principles for information flow, business processes, and management reporting.
• Develop collaborative relationships with business partners and vendors.
• Inform and advise management on California Department of Health Care Services trends and activities.
• Own operational accountability for system conversions.
• Identify and resolve technical, operational, and organizational problems.
• Lead teams to resolve business problems affecting multiple functions.
• Lead and influence staff by fostering teamwork, collaboration, and diversity & inclusion.
• Drive high‑quality execution with clear directions and expectations.
• Review and approve workflows, business processes, and requirements documentation for all claims functions.
• Monitor and provide oversight of delegated entities concerning claims compliance.
• Prepare materials for internal and external regulatory audits and legal requests.
• Address escalating claims issues with providers and members promptly and courteously.
• Manage staff selection, evaluation, training, and development.
• Translate strategic goals into specific operating and resource plans.
• Coordinate and supervise operational analyses and implementation support on major workflow and system modifications.
• Act as a consultant for senior management on reimbursement methodologies, regulatory requirements, and claims protocols.
• Work with recovery vendor to identify funds paid in error and recover those funds.
• Manage and develop the annual budget for the claims department.
• Maintain external contact with regulatory agencies, providers, and community-based organizations.
• Perform other duties as assigned.
• Apply principles and practices of health care delivery, Medi‑Cal eligibility, benefits, billing/coding, COB/TPL regulations.
• Operate claims systems and track performance metrics.
• Understand theories of claims administration and customer service for a diverse population.
• Apply state and federal regulations related to Medi‑Cal managed care.

• High School Graduate or GED.
• 8+ years professional experience managing a claims processing department, preferably in a Medi‑Cal/Medicaid managed care plan.
• Excellent understanding of claims regulatory requirements (AB1455, AB97, COB, NCCI).

• Excellent analytical ability, judgment, and problem‑solving.
• Ability to present complex information understandably.
• Policy evaluation and revision skills.
• Develop and implement operational and service…