Program Manager - Claims, Health Plan

SCAN; Long Beach (CA); Remote; USD 106.000 - 154.000; Vollzeit

Benefits dieser Stelle

Base salary $106,200 to $153,705 per $

Mostly remote work

Annual bonus program

Wellness program

PTO and holidays

401(k) with employer match

Tuition reimbursement

Recognition program

Zusammenfassung

SCAN is seeking a Program Manager - Claims to lead escalations, pricing, and policy interpretation for AEP/OEP, ensuring adjudication per contracts and regulatory requirements. You will collaborate with providers, members, Medical Management, Coding, Billing, and Finance to resolve complex issues and drive cost savings.

You will guide data analysis to identify trends, support Total Cost of Care initiatives, and help plan staffing and vendor relationships.

Qualifikationen

• Bachelor's degree or equivalent in business/healthcare administration.
• 5+ years of progressive experience in healthcare claims operations or a related health plan function.
• 2-3 years of leadership experience.
• Experience with Medicare Advantage claims operations and regulatory requirements preferred.
• Strong knowledge of claims adjudication, claims operations, pricing, and applicable policies, contracts, and regulatory requirements.
• Ability to interpret NCD/LCD and other payment policies.

Aufgaben

• 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.

Kenntnisse

Leadership

Claims analysis

Cross-functional collaboration

SQL

Problem solving

Communication

Project management

Ausbildung

Bachelor's degree in business/healthcare

Tools

Microsoft Office

Visio

SQL

Jobbeschreibung

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.

Program Manager - Claims

The role 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.

Your Qualifications

• 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.
• Experience with Medicare Advantage claims operations and regulatory requirements preferred.
• Strong knowledge of claims adjudication, claims operations, pricing, and applicable policies, contracts, and regulatory requirements.
• Ability to interpret National Coverage Determinations and Local Coverage Determinations (NCD/LCD) and other payment policies.
• Demonstrated ability to investigate and resolve complex, high-dollar, and escalated claims.
• Strong analytical skills with the ability to identify trends, operational problems, cost savings, and process improvement opportunities.
• Ability to collaborate effectively with providers, members, Medical Management, Coding, Billing, Finance, Network Management, vendors, and external partners.
• Program and project management skills, including the ability to lead multiple priorities and deliver results.
• Ability to support staffing plans, and resource allocation.
• Experience supporting system implementations, testing, claims-platform upgrades, and workflow changes.
• Strong written and verbal communication skills, including the ability to present issues and resolution solutions to senior leadership.
• Ability to work independently, exercise sound judgment, and manage sensitive or highly escalated matters.
• Leadership – Skilled to develop others
• Problem Solving – Strong problem‑solving skills
• Optimizes Work Processes – Identifies and creates processes necessary to get work done
• Advanced Microsoft Office Suite, Visio, and SQL experience are required.

What's in it for you?

• Base salary range: $106,200 to $153,705 per year
• Work Mode: Mostly Remote
• An annual employee bonus program
• Robust Wellness Program
• Generous paid‑time‑off (PTO)
• Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
• Excellent 401(k) Retirement Saving Plan with employer match and contribution
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Equal Opportunity Employer/Protected Veterans/Individuals With Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information.