Full Job Description
**This role is open to California residents only.**
ESSENTIAL FUNCTIONS
• Provides strategic and operational leadership for the Claims Execution organization, ensuring the timely, accurate, compliant, and cost-effective execution of all operational work performed within Claims Operations.
• Directs the day-to-day management of operational work queues including operational intake, complex claims processing, provider dispute resolution (PDR), encounter operations, adjustments and reprocessing, member reimbursements, correspondence management, check run operations, and other assigned operational functions.
• Serves as the department subject matter expert in operational inventory management, workload prioritization, capacity planning, queue governance, aging management, and operational performance.
• Establishes and maintains operational standards, workflows, service level expectations, and performance metrics to ensure consistent execution and effective inventory management across all Claims Execution functions.
• Provides operational oversight and performance management of the Business Process Outsourcing (BPO) claims processing vendor, including production performance, quality, inventory management, turnaround times, service level agreement compliance, issue resolution, and continuous operational improvement.
• Monitors operational inventories, identifies emerging risks, capacity constraints, backlog trends, and aging work items, and implements corrective actions to maintain operational performance and regulatory compliance.
• Leads, develops, coaches, and evaluates management and staff within Claims Execution, fostering a culture of accountability, operational excellence, continuous improvement, and customer service.
• Establishes operational priorities and allocates resources to ensure workloads are balanced, service levels are achieved, and organizational priorities are effectively executed.
• Partners with Claims Business Operations to identify operational defects, workflow inefficiencies, automation opportunities, and business improvement initiatives that improve operational performance and reduce manual work.
• Collaborates with Configuration, Information Technology, Finance, Compliance, Provider Network Operations, Payment Integrity, Customer Service, and other internal and external business partners to resolve operational issues and support enterprise initiatives.
• Ensures compliance with all applicable federal and state regulatory requirements, contractual obligations, organizational policies, and operational standards governing Claims Operations.
• Oversees operational readiness and implementation of new regulatory requirements, business initiatives, products, systems, and organizational changes impacting Claims Execution.
• Monitors departmental performance through key performance indicators, operational dashboards, inventory metrics, quality measures, and service level reporting, taking corrective action as necessary to achieve operational goals.
• Develops and maintains departmental procedures, operational controls, and standard operating practices that promote consistency, quality, efficiency, and regulatory compliance.
• Represents Claims Execution in cross-functional committees, operational governance meetings, vendor meetings, regulatory discussions, and executive leadership forums.
• Identifies opportunities to improve provider and member experience by reducing operational defects, improving turnaround times, strengthening operational controls, and enhancing service delivery.
• Performs other duties as assigned.
MINIMUM QUALIFICATIONS
Education & Experience:
• Bachelor's degree in Business Administration, Healthcare Administration, Public Administration, or a related field; or an equivalent combination of education and progressively responsible experience in managed healthcare operations. Master's degree preferred.
• Minimum eight (8) years of progressively responsible experience in managed care claims operations, including leadership responsibility for claims processing, operational management, provider dispute resolution, encounter operations, payment operations, or related healthcare administrative functions.
• Minimum five (5) years of leadership experience managing operational teams, supervisors, managers, or large-scale operational functions within a managed care, health plan, third-party administrator (TPA), or healthcare payer environment.
• Demonstrated experience leading complex operational organizations with responsibility for inventory management, workload planning, operational performance, quality, regulatory compliance, and service delivery.
• Demonstrated experience managing or overseeing outsourced operational services, vendor relationships, or Business Process Outsourcing (BPO) operations is highly desirable.
• Demonstrated experience leading operational change initiatives, workflow redesign, process improvement, automation initiatives, or organizational transformation efforts.
Equivalent In lieu of degree: Will accept experience in any combination of academic education, professional training, or work experience, which demonstrates the ability to perform the duties of the position.
KNOWLEDGE, SKILLS & ABILITIES
• Commercial, Medi-Cal, Medicare, and managed care claims processing operations.
• Claims adjudication processes, reimbursement methodologies, and payment operations.
• Provider Dispute Resolution (PDR) regulations and operational requirements, including AB 1455 and other applicable state and federal requirements.
• Encounter data management, encounter submission processes, regulatory reporting requirements, and encounter quality principles.
• Operational inventory management, workload balancing, queue management, and capacity planning methodologies.
• Claims operational performance metrics, service level management, quality assurance, and continuous improvement principles.
• Provider contracts, reimbursement methodologies, Division of Financial Responsibility (DOFR), and claims payment policies.
• Coordination of Benefits (COB), Third-Party Liability (TPL), and related claims operations.
• Medical terminology, CPT, HCPCS, ICD-10, and healthcare reimbursement concepts.
• Applicable federal and state regulations governing managed care claims operations.
Technology & Software Skills: Advanced computer skills in MS Office products.
Certifications & Licenses: N/A
The estimated pay range for the position is:
$157,303.00 - $262,697.00
The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.
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