FLSA Status: Exempt
Department: Operations
Reports To: Chief Operating Officer
GENERAL DESCRIPTION OF POSITION
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.
ESSENTIAL DUTIES AND RESPONSIBILITIES
To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.
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. Lead interdepartmental initiatives with clear objectives, deliverables, timelines, and success metrics.
7. 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 SCFHP’s 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. Attend offsite meetings or events as necessary. Perform other duties as required or assigned.
SUPERVISORY/MANAGEMENT RESPONSIBILITIES
Carries out supervisory/management responsibilities in accordance with SCFHP’s 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. Responsibilities include:
1. Modeling and promoting SCFHP’s values across all operational teams; serve as a thought partner and coach to Director-level leaders, supporting their growth and fostering a culture of accountability, collaboration, and continuous learning.
2. Identifying and implementing professional development opportunities to build staff capabilities and support succession planning across operational departments.
3. Providing effective leadership to attract and retain top talent, including recruiting, interviewing, and hiring.
4. Setting goals, assigning and directing work, and ensuring employees have the resources needed to perform effectively.
5. Appraising performance, addressing complaints, resolving issues, and providing regular, objective feedback through timely performance reviews.
REQUIREMENTS – Required (R) Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.
1. Bachelor’s Degree in Healthcare Administration, Business Administration, Public Administration, or a related field; or equivalent experience. (R)
2. Master’s Degree in Healthcare Administration, Business Administration, Public Administration. (D)
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. (R)
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. (R)
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. (R)
6. Experience in vendor management, contract administration, and procurement in a regulated healthcare environment;. (D)
7. Proven ability to improve service levels in contact center environments. (R)
8. Data-driven leadership style with strong financial acumen; demonstrated ability to scale operations while maintaining community-based responsiveness and leading through influence across organizational boundaries. (R)
9. Excellent written and oral communication skills; ability to express ideas clearly across all organizational levels, with external constituents and regulators, in person, in writing, and in presentations. (R)
10. Strong analytical and critical thinking skills; ability to interpret complex data, apply regulatory guidance, manage competing priorities, and drive projects to completion with sound judgment. (R)
11. Knowledge of community agencies and support services for underserved populations. (D)
12. Ability to maintain confidentiality and comply with all SCFHP policies and procedures. (R)
13. Strong proficiency with MS Office Suite including Outlook, Word, Excel, PowerPoint, and Visio; ability to use a keyboard with moderate speed and high accuracy. (R)
Perform the job safely and with respect to others, to property, and to individual safety. (R)
WORKING CONDITIONS
Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.
PHYSICAL REQUIREMENTS
Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:
1. Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
2. Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
3. Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
4. Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
5. Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
6. Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)
ENVIRONMENTAL CONDITIONS
General office conditions. May be exposed to moderate noise levels.
Pay: $254,696.00 - $407,514.00 per year
Work Location: Hybrid remote in San Jose, CA 95119
