San Francisco Health Plan
Program Manager, Clinical Operations
San Francisco Health Plan, San Francisco, California, United States, 94199
Overview
Reporting to the Manager of Clinical Operations Administration, the Program Manager is responsible for planning, implementing, and managing multiple interconnected projects within the utilization management department. You will focus on program operations, regulatory compliance, and process improvement. You will guide initiatives that are strategic and improvement oriented in nature and coordinates departmental activities focused on adherence to regulatory requirements and accreditation standards – DHCS, DMHC, CMS, and NCQA. As the department's primary subject matter expert on regulatory and accreditation requirements, you are ensuring process compliance audit readiness. By leading cross-functional teams, you will manage resources and communicate with partners to ensure successful program and project outcomes.
Base Pay Base pay range: $90,000.00/yr - $105,000.00/yr
Responsibilities
Develop and implement strategies to optimize the utilization management (UM) department, ensuring alignment with organizational goals.
Author programmatic documents including program description, evaluation, workplan, charters, business requirements, status reports, meeting minutes, and policies.
Monitor and evaluate program outcomes, and recommend improvements based on data analysis and stakeholder feedback.
Coordinate the Utilization Management Committee (UMC).
Participate in UM delegation oversight activities and meetings.
Lead implementation of new UM regulatory requirements (e.g., CMS, DHCS APLs, NCQA).
Evaluate regulatory requirements, perform gap analyses, and manage the process for compliance activities, including updating policies, procedures, workflows, and reports to reflect changes.
Maintain centralized audit readiness infrastructure, prepare regulatory audit submissions, and ensure timely evidence delivery.
Qualifications
Bachelor's degree in health care administration or related field; or equivalent experience. Master's degree in healthcare is preferred.
Minimum 2 years of experience in health care delivery or health plan settings; familiarity with Medi-Cal or Department of Health Services regulations; knowledge of medical terminology and managed care concepts. Utilization Management/Medical Management experience is preferred.
Working knowledge of NCQA and Care Management systems.
Minimum 2 years managing moderate-sized projects, ideally in Utilization Management.
Experience with care management systems such as Jiva or EPIC.
What We Offer
Medical: Choice of medical plans, including options from Kaiser and Blue Shield of California, subsidized by SFHP.
Dental: Basic or enhanced dental plans with orthodontic coverage.
Vision: Vision coverage through Vision Service Plan (VSP).
Retirement: Employer-matched CalPERS Pension and 401(a), 457 Plan.
Time off: 23 days of Paid Time Off (PTO) and 13 paid holidays.
Professional development: Tuition reimbursement and support for professional licenses/memberships.
About SFHP Established in 1997, San Francisco Health Plan (SFHP) is an award-winning managed care health plan serving underserved low- and moderate-income residents in San Francisco County. SFHP serves a broad membership with access to preventive care, specialty care, hospitalization, prescription drugs, and family planning services.
SFHP is an equal opportunity employer. We are committed to a work environment that respects all individuals and applies our people processes without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.
Pursuant to the San Francisco Fair Chance Ordinance, SFHP will consider qualified applicants with arrest and conviction records.
SFHP is an E-Verify participating employer.
Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.
Job Details
Seniority level: Mid-Senior level
Employment type: Full-time
Job function: Project Management and Other
Industries: Hospitals and Health Care and Insurance
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Base Pay Base pay range: $90,000.00/yr - $105,000.00/yr
Responsibilities
Develop and implement strategies to optimize the utilization management (UM) department, ensuring alignment with organizational goals.
Author programmatic documents including program description, evaluation, workplan, charters, business requirements, status reports, meeting minutes, and policies.
Monitor and evaluate program outcomes, and recommend improvements based on data analysis and stakeholder feedback.
Coordinate the Utilization Management Committee (UMC).
Participate in UM delegation oversight activities and meetings.
Lead implementation of new UM regulatory requirements (e.g., CMS, DHCS APLs, NCQA).
Evaluate regulatory requirements, perform gap analyses, and manage the process for compliance activities, including updating policies, procedures, workflows, and reports to reflect changes.
Maintain centralized audit readiness infrastructure, prepare regulatory audit submissions, and ensure timely evidence delivery.
Qualifications
Bachelor's degree in health care administration or related field; or equivalent experience. Master's degree in healthcare is preferred.
Minimum 2 years of experience in health care delivery or health plan settings; familiarity with Medi-Cal or Department of Health Services regulations; knowledge of medical terminology and managed care concepts. Utilization Management/Medical Management experience is preferred.
Working knowledge of NCQA and Care Management systems.
Minimum 2 years managing moderate-sized projects, ideally in Utilization Management.
Experience with care management systems such as Jiva or EPIC.
What We Offer
Medical: Choice of medical plans, including options from Kaiser and Blue Shield of California, subsidized by SFHP.
Dental: Basic or enhanced dental plans with orthodontic coverage.
Vision: Vision coverage through Vision Service Plan (VSP).
Retirement: Employer-matched CalPERS Pension and 401(a), 457 Plan.
Time off: 23 days of Paid Time Off (PTO) and 13 paid holidays.
Professional development: Tuition reimbursement and support for professional licenses/memberships.
About SFHP Established in 1997, San Francisco Health Plan (SFHP) is an award-winning managed care health plan serving underserved low- and moderate-income residents in San Francisco County. SFHP serves a broad membership with access to preventive care, specialty care, hospitalization, prescription drugs, and family planning services.
SFHP is an equal opportunity employer. We are committed to a work environment that respects all individuals and applies our people processes without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.
Pursuant to the San Francisco Fair Chance Ordinance, SFHP will consider qualified applicants with arrest and conviction records.
SFHP is an E-Verify participating employer.
Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.
Job Details
Seniority level: Mid-Senior level
Employment type: Full-time
Job function: Project Management and Other
Industries: Hospitals and Health Care and Insurance
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