Location: Fully onsite in Huntington Beach, CA. Candidates must be able to commute to the office five days per week.
Description: The Director of Claims will provide strategic leadership for all Medicare Advantage claims operations, ensuring accurate, timely, and compliant claims adjudication while driving operational excellence. This individual will oversee claims processing, lead high-performing teams, manage vendor relationships, ensure regulatory compliance, and partner across the organization to optimize claims performance, payment integrity, and member and provider satisfaction.
What You Will Do: - Lead all aspects of Medicare Advantage claims operations, including claims intake, adjudication, adjustments, payment integrity, and recovery activities.
- Ensure compliance with CMS Medicare Advantage regulations, encounter data submission requirements, and prompt pay standards.
- Monitor and improve key operational metrics including turnaround times, auto-adjudication rates, claims accuracy, and inventory management.
- Develop, mentor, and lead a high-performing claims operations team focused on quality, service, and continuous improvement.
- Partner closely with Configuration, Provider Network, Compliance, Appeals & Grievances, IT, and Provider Relations to improve claims operations and resolve complex issues.
- Oversee relationships with TPAs, clearinghouses, and other delegated vendors while ensuring service level agreements are achieved.
- nalyze claims trends, denial patterns, and operational data to identify opportunities for process improvement and cost savings.
- Support CMS audits, regulatory reviews, and corrective action plans while maintaining compliance with federal and state requirements.
- Manage departmental budgets, staffing, forecasting, and executive reporting.
- Stay current on evolving Medicare Advantage regulations and proactively implement operational changes.
You Will Be Successful If: - You have extensive Medicare Advantage claims leadership experience within a health plan or managed care organization.
- You thrive in a fast-paced, highly regulated healthcare environment.
- You have a proven ability to improve operational performance through data-driven decision making and process improvement.
- You build strong partnerships across clinical, operational, compliance, and technology teams.
- You are an effective leader who develops high-performing teams while driving accountability and operational excellence.
- You are comfortable presenting operational performance and regulatory updates to executive leadership.
What You Will Bring: - Bachelor's degree in Healthcare Administration, Business, or a related field (Master's degree preferred).
- 7 to 10+ years of progressive claims management experience within a health plan, managed care organization, or TPA, including at least 3 to 5 years in a leadership role.
- Deep expertise in Medicare Advantage claims processing, CMS regulations, encounter data submissions, and payment integrity.
- Experience with healthcare claims platforms such as QNXT, HealthRules Payer, Facets, MHK, ika, or similar systems.
- Strong knowledge of ICD-10, CPT, HCPCS coding, reimbursement methodologies, and claims auditing.
- Experience managing CMS audits, regulatory examinations, and vendor relationships.
- Exceptional leadership, communication, analytical, and organizational skills.
- Preferred experience supporting Medicaid and D-SNP claims, fraud, waste and abuse initiatives, Lean or Six Sigma methodologies, and claims system implementations or migrations.
