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Health Plan Operations Jobs in California (NOW HIRING)

Community Health System

Sr. Auditor, Health Plan

Fresno, CA · On-site +1

$46.52 - $59.20/hr

The Senior Auditor oversees and performs financial, operational, and technology audits and other ... California Health Plan experience preferred * Experience working with QNXT is a plus. Licenses and ...

Community Health System

Sr. Auditor, Health Plan

Fresno, CA · On-site +1

$46.52 - $59.20/hr

Responsibilities The Senior Auditor oversees and performs financial, operational, and technology ... California Health Plan experience preferred * Experience working with QNXT is a plus. Licenses and ...

Community Health System

Sr. Auditor, Health Plan

Fresno, CA · On-site

$46.52 - $59.20/hr

Responsibilities The Senior Auditor oversees and performs financial, operational, and technology ... California Health Plan experience preferred * Experience working with QNXT is a plus. Licenses and ...

Community Health System

Sr. Auditor, Health Plan

Fresno, CA · On-site +1

$80K - $98K/yr

ResponsibilitiesThe Senior Auditor oversees and performs financial, operational, and technology ... California Health Plan experience preferred * Experience working with QNXT is a plus. Licenses and ...

Abby Care

Health Plan Strategy Lead

San Francisco, CA · On-site

$150K - $200K/yr

Our Health Plan Strategy team reports directly to Abby Care's CEO. We own the company's payor ... Conduct deep market and operational research to guide the strategic positioning, parameter design ...

Abby Care

Health Plan Strategy Lead

San Francisco, CA · On-site

We're looking for a Health Plan Strategy Lead to architect the strategy, economics, and regulatory ... Conduct deep market and operational research to guide the strategic positioning, parameter design ...

Community Medical Centers

Sr. Auditor, Health Plan

Fresno, CA · On-site

$80K - $98K/yr

Responsibilities The Senior Auditor oversees and performs financial, operational, and technology ... California Health Plan experience preferred * Experience working with QNXT is a plus. Licenses and ...

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Health Plan Operations information

What is health plan operations?

Health Plan Operations refer to the processes and activities involved in managing the daily functions of a health insurance plan. This includes tasks such as member enrollment, claims processing, provider network management, customer service, regulatory compliance, and quality assurance. Effective health plan operations ensure smooth delivery of healthcare benefits to members, maintain accurate records, and support financial and regulatory goals for the organization. These operations are crucial for delivering high-quality service and maintaining the trust of both providers and members.

What are the key skills and qualifications needed to thrive in health plan operations?

To excel in Health Plan Operations, a strong background in healthcare administration, data analysis, and regulatory compliance is essential, often supported by a bachelor's degree in healthcare management or a related field. Familiarity with claims processing systems, health information management software, and knowledge of HIPAA regulations are typically required. Exceptional organizational skills, attention to detail, and effective communication set high performers apart in this role. These skills ensure efficient health plan administration, regulatory adherence, and optimal service delivery to members and providers.

What are some common challenges faced in a health plan operations role, and how can new hires prepare to address them?

Professionals in Health Plan Operations often encounter challenges such as navigating complex regulatory requirements, managing cross-functional communication, and ensuring process efficiency while maintaining compliance. New hires can prepare by familiarizing themselves with relevant healthcare regulations (like HIPAA and ACA), developing strong organizational and analytical skills, and being proactive in collaborating with teams such as claims, provider relations, and IT. Building a solid understanding of internal procedures and fostering relationships across departments can help streamline workflows and address operational issues more effectively.

What is the difference between Health Plan Operations vs Claims Processor?

AspectHealth Plan OperationsClaims Processor
Primary RoleOversees overall health plan functions, including member services, provider relations, and complianceReviews and processes individual insurance claims for payment
Required CredentialsTypically requires knowledge of healthcare regulations, insurance policies, and sometimes certifications in health administrationOften requires familiarity with claims processing systems and basic insurance knowledge
Work EnvironmentOffice-based, collaborative teams, health insurance companies or managed care organizationsOffice or call center, focused on claims review and data entry

Health Plan Operations professionals manage the broader functions of health insurance plans, ensuring compliance and member satisfaction, while Claims Processors focus specifically on evaluating and processing insurance claims. Both roles are essential in the healthcare insurance industry but differ in scope and responsibilities.

What do you do in health plan operations?

Health plan operations professionals manage the daily functions of health insurance plans, including claims processing, member enrollment, provider network management, and compliance with healthcare regulations. They often use specialized software and require strong organizational and communication skills to ensure efficient plan administration.
Health Plan Operations jobs near you

Health Plan Contracting Manager

Sherman Oaks, CA • On-site

MedPOINT Management
Outpatient Health Care • 501 - 1,000 employees
Learn more about MedPOINT Managementexternal

$160K - $185K/yr

Full-time

Medical, Dental, Vision, Retirement, PTO

Posted 17 days ago

Job description

Benefits:
  • 401(k)
  • 401(k) matching
  • Bonus based on performance
  • Company parties
  • Dental insurance
  • Employee discounts
  • Health insurance
  • Opportunity for advancement
  • Paid time off
  • Parental leave
  • Savings bank
  • Training & development
  • Vision insurance
  • Wellness resources

About the Role:
MedPOINT Management is looking for a driven and detail-oriented Health Plan Contracting Manager to join our team in Sherman Oaks, CA. In this pivotal role, you'll lead the negotiation and management of health plan contracts, playing a key part in shaping the financial and operational success of our organization. If you thrive in a fast-paced healthcare environment and have a passion for building strong payer relationships, we want to hear from you.
Responsibilities:
  • Negotiate, review, and manage contracts with health plans, IPAs, and managed care organizations
  • Analyze contract terms, reimbursement rates, and fee schedules to ensure financial viability
  • Serve as the primary point of contact for health plan partners and payer relations
  • Monitor contract compliance and ensure adherence to regulatory and contractual obligations
  • Collaborate with internal teams including finance, operations, and legal to support contract implementation
  • Track contract renewals, amendments, and terminations to maintain an up-to-date contract repository
  • Identify opportunities to improve payer agreements and optimize reimbursement strategies
Requirements:
  • 3+ years of experience in health plan contracting, managed care, or payer relations
  • Strong knowledge of managed care concepts, capitation, fee-for-service, and value-based contracts
  • Experience working with IPAs, MSOs, or physician groups preferred
  • Excellent negotiation, analytical, and communication skills
  • Proficiency in contract management software and Microsoft Office Suite
  • Bachelor's degree in Healthcare Administration, Business, or a related field
  • Highly organized, self-motivated, and able to manage multiple priorities simultaneously
About Us:
MedPOINT Management is a leading Independent Practice Association (IPA) management services organization based in Sherman Oaks, CA, dedicated to supporting physician groups and healthcare providers across Southern California. We are known for our commitment to operational excellence, innovative managed care solutions, and delivering outstanding service to both our provider partners and the patients they serve. Our team enjoys a collaborative, mission-driven culture where expertise is valued and professional growth is encouraged.

Flexible work from home options available.