Program Manager, Clinical Operations

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.

Please note that while SFHP supports a hybrid work environment, you are required to be onsite and in-office a minimum of 4 days per month. This is a hybrid position, based in our Downtown San Francisco office.

Salary: $90,000 to $105,000 per year

WHAT YOU WILL DO:

• Develop and implement strategies to optimize the utilization management (UM) department, ensuring alignment with organizational goals.
• Author programmatic documents including, but not limited to, program description, evaluation, workplan, charters, business requirements, status reports, meeting minutes, and policies.
• Monitor and evaluate program outcomes, making recommendations for improvements based on data analysis and 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 requirements, complete gap analyses, and manage the process for compliance activities, including communicating requirement changes and updating policies, procedures, workflows, reports, etc., to comply with updated requirements.
• Maintain centralized audit readiness infrastructure, prepare regulatory audit submissions, and ensure timely evidence delivery.

WHAT YOU WILL BRING:

• Bachelor's degree in health care administration or a related field; or equivalent experience. Master's degree in healthcare field is desired.
• Minimum 2 years of experience working in health care delivery system or health plan experience; experience with Medi-Cal or Department of Health Services regulations; knowledge of medical terminology and concepts of managed care. Experience in Utilization Management/Medical Management preferred.
• Working knowledge of NCQA and Care Management systems.
• Minimum 2 years managing moderate sized projects, ideally for Utilization Management departments.Experience with care management systems such as Jiva, Essette, or EPIC.

WHAT WE OFFER:

• Health Benefits
  
  
  
  • Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
  • Dental: You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
  • Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
  
  
  
  
• Retirement - Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
• Time off - 23 days of Paid Time Off (PTO) and 13 paid holidays.
• Professional development: Opportunities for tuition reimbursement, professional license/membership.

ABOUT SFHP:

Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.

San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied 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, we will consider for employment qualified applicants with arrest and conviction records.

San Francisco Health Plan is an E-Verify participating employer.

Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.

#LI-Hybrid

(Hybrid remote/in-office)

PI277283822