Description

About the role:

The Vice President, Operations is a senior executive leader responsible for ensuring strategic alignment, regulatory adherence, operational excellence, and a culture of continuous improvement of core health plan operations (enrollment and eligibility, customer service, grievances and appeals, and vendor management). In this role, the Vice President, Operations holds organizational accountability for regulatory and audit oversight, technology enablement, member experience, and leadership and talent development, and represents SCFHP externally with business partners, delegates, and regulators.

Day to Day:

1. Provide strategic oversight and executive accountability for Enrollment and Eligibility, Customer Service, Grievances and Appeals, and Vendor Management, ensuring each functional area meets performance, compliance, and service quality standards.

2. Provide oversight and direction to the Director, Operations to ensure effective and compliant Enrollment and Eligibility and Grievances and Appeals operations, including root cause analysis, regulatory reporting, and improvement initiatives.

3. Provide oversight and direction to the Director, Customer Service to ensure department operations deliver a consistent, high-quality member and provider service experience, including transportation coordination and escalation resolution.

4. Maintain organizational accountability for Vendor Management; establish and sustain vendor strategy, contract lifecycle standards, and performance frameworks in coordination with business unit leads, Compliance and legal counsel.

5. Work with departmental leadership to develop and monitor individual objectives and departmental budgets across all areas of responsibility, reviewing performance regularly and ensuring responsible resource management.

6.Maintain current knowledge of federal and state regulations governing health plan operations, including DHCS and CMS requirements, APLs, DPLs, and Medicare Managed Care Manual provisions; ensure these requirements are translated into operational policies, procedures, and reporting standards across all supervised functions.

8. Represent SCFHP in external regulatory meetings and compliance audits, oversee identification and remediation of compliance gaps, and ensure timely corrective action across operational departments.

9. Champion a culture of continuous improvement across all operational areas; identify and sponsor workflow optimization and process improvement initiatives to drive efficiency, accuracy, and quality.

10. Provide oversight for system technology implementation, including evaluation of technology investments and operational enhancements; maintain performance dashboards and reporting frameworks to support data-informed decision-making.

11. Champion the member experience as a strategic priority; analyze trends across grievances and appeals, customer service data, and member feedback to identify systemic gaps and oversee interventions that reflect SCFHPs commitment to accessibility, equity, and service excellence.

12. Represent SCFHP externally with providers, delegates, community stakeholders, and regulators; collaborate with internal departments on communications and resources that support member and provider understanding of health plan services.

13.Carries out supervisory/management responsibilities in accordance with SCFHPs policies, procedures, applicable regulations and laws. The VP, Operations exercises direct supervisory accountability for the Director, Operations; Director, Customer Service; and Vendor Management Contract Managers.

About you:

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. Bachelors Degree in Healthcare Administration, Business Administration, Public Administration, or a related field; or equivalent experience.

2. Masters Degree in Healthcare Administration, Business Administration, Public Administration. (Desired)

3. Minimum of ten years of senior-level managed care leadership experience, including significant exposure to enrollment and eligibility, grievances and appeals, customer service/contact center operations, and/or provider network management.

4. Demonstrated experience in Medi-Cal and/or Medicare health plan operations, with working knowledge of how operational performance influences Medicare Star Ratings, HEDIS measures, and regional healthcare market dynamics.

5. Deep understanding of health plan regulatory requirements, including DHCS and CMS standards, APLs, DPLs, and managed care compliance, with strong command of appeals and grievance regulatory requirements.