Operations Manager

Role Overview

• Serve as the day-to-day operational owner of Pear Suite or similar for CalAIM Community Supports billing.
• Manage and oversee the end-to-end claims lifecycle, from generation through screening, approval, submission, and final resolution.
• Ensure claims are reviewed, approved, and submitted according to internal/Funder/DHCS
• QC standards and payer timelines.
• Monitor claim statuses and system dashboards to identify risks, delays, or systemic issues.
• Monitor and enforce CalAIM billing timeliness requirements, including retroactive billing windows and corrected claim resubmission deadlines.
• Oversee processes for PMPM billing logic and expected denial patterns to ensure accurate and compliant billing outcomes..
• Support monitoring of service-specific lifetime caps (e.g., housing deposits, environmental accessibility adaptations).
• Coordinate with program and compliance stakeholders when caps or billing limits are nearing or have been reached to ensure appropriate action.
• Lead denial, rejection, and correction management processes, including review of ERA feedback and denial reason codes.
• Determine appropriate paths (corrective action versus claim closure) and ensure corrected claims are reissued within resubmission limits.
• Track and analyze denial and rejection trends; escalate issues that indicate upstream data, workflow, or system configuration gaps.
• Manage denial and correction logs, ensuring complete documentation to support audits, reporting, and continuous improvement.
• Identify and implement opportunities to improve billing workflows and improve efficiency to ensure clean claim rates.
• Ensure compliance and quality control by contributing to the refinement of SOPs, job aids, and internal controls, and ensuring billing processes align with CalAIM, DHCS, health plan, and contractual requirements.
• Support the onboarding of new regions, payers, and Community Supports as CalAIM expands.

Requirements

• At least 2 years of experience in billing, claims, or revenue cycle management, preferably in healthcare, Medicaid, or public sector programs.
• Preferred experience managing claims workflows and payer rules, including denials and corrections.
• Experience working with billing and claims technology platforms (e.g., Pear Suite, clearinghouses, or comparable systems).
• Experience supporting audits and compliance reviews strongly preferred.
• A minimum of 3 years working in a social justice, human services, non-profit management, healthcare, or public policy agency.
• At least two years of experience building and managing teams, experience overseeing contracts, budgets, and invoicing processes.
• Demonstrated leadership as evidenced by increasing levels of responsibility and management over the course of the candidate’s career.
• Familiarity with accounting principles, government contracting, and business process optimization.
• Demonstrated ability in leveraging data to drive strategic decision‑making and system improvements.
• Strategic and systems‑oriented leader with the ability to design, implement, and sustain inclusive and transparent decision‑making frameworks.
• Strong communication, critical thinking, and independent judgment skills, with a creative and solution-oriented mindset.
• Highly organized with strong project management, planning, and prioritization abilities, able to perform effectively under pressure and refine systems with a holistic, “big picture” perspective..
• Effective communicator with the ability to lead, influence, and collaborate across diverse and cross‑cultural environments using an equity‑centered approach.
• Proficiency with MS Outlook, Word, PowerPoint and Excel required; experience with databases such as Salesforce preferred.
• Intacct software experience preferred but not required

Benefits

• Health Care Plan (Medical, Dental, & Vision)
• Retirement Plan (With 5% Match)
• Life Insurance (Basic, Voluntary and AD&D)
• Paid Time Off (Vacation, Sick & Public Holidays)
• Family Leave (Maternity, Paternity)
• Short Term & Long-Term Disability
• Training & Development
• Wellness Resources
• Hybrid Work