Program Manager - Claims, Health Plan

Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do. Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue.

With nearly five decades of experience, we have built a distinctive, values‑driven platform dedicated to improving care for older adults. Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next‑generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity.

At SCAN, we believe scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve.

The Program Manager
- Claims is accountable for claims escalations, provider abrasion, service issues, pricing, payment policy interpretation, and the investigation and resolution of complex, high-dollar claims. This role ensures claims are adjudicated according to policies, contracts, and regulatory requirements; collaborates with internal and external partners to resolve issues; and analyzes data to identify trends, operational problems, cost savings, and process improvement opportunities. The position leads claims triage and management for AEP/OEP, supports Total Cost of Care initiatives, and works directly with senior leadership to develop resolution solutions for escalated cases.

You Will Manage claims escalations, provider abrasion, service issues, pricing matters, and payment policy interpretation. Investigate and resolve complex, high-dollar claims and ensure claims are adjudicated according to policies, contracts, and regulatory requirements. Work with providers, members, Medical Management, Coding, Billing, and Finance to resolve claims issues. Analyze claims and operational data to identify trends, operational problems, cost savings, and process improvement opportunities.

Collaborate with Network Management and work directly with external partners, as needed, to address claims‑related issues. Lead claims triage and management for the Annual Enrollment Period and Open Enrollment Period (AEP/OEP). Support Total Cost of Care initiatives by identifying and implementing opportunities to improve efficiencies. Support staffing plans and resource allocation for claims programs and initiatives. Manage vendor or third‑party claims relationships, when applicable.

Support system implementations and claims‑platform upgrades, including leading testing and workflow changes, and partner with senior leadership to develop resolution solutions for escalated cases.

We seek Rebels who are curious about AI and its power to transform how we operate and serve our members. Actively support the achievement of SCAN’s Vision and Goals. Other duties as assigned.

Bachelor's Degree or equivalent experience in Business Administration, Healthcare Administration, Finance, or a related field; or an equivalent combination of education and experience. 2-3 years of leadership experience. 5 or more years of progressive experience in healthcare claims operations, claims analysis, or a related health plan function. Experience managing cross‑functional programs, complex claims issues, vendors, or claims‑related initiatives.

Experienc…