Claims Director

County of Contra Costa • Martinez, CA

1d

About The Position

Contra Costa Health is offering an excellent opportunity for a Health Plan Division Director – Exempt (Claims Director) within Contra Costa Health Plan (CCHP). This role plays a key leadership function within CCHP, providing strategic and operational oversight of the claims function to ensure accurate, timely, and compliant payment of healthcare services. It is responsible for setting directions, establishing controls, and guiding continuous improvement across claims operations while supporting positive provider relationships, regulatory compliance, and the financial integrity of the health plan. The position works closely with executive leadership and cross-functional partners to align claims operations, with accountability for claims adjudication, payment integrity, regulatory compliance, and vendor oversight across Medi-Cal, Medicare, and commercial lines of business. This role ensures claims operations support member access, provider relationships, and the financial integrity of the health plan.

About Contra Costa Health Plan: CCHP is a federally qualified, state-licensed, county-sponsored Health Maintenance Organization serving more than 250,000 residents of Contra Costa County. As part of Contra Costa Health, the County’s integrated public health system, the health plan plays a central role in delivering accessible, high-quality care to a diverse population. CCHP’s primary business line is Medi-Cal but also has a growing D-SNP product line as well as Commercial lines of business.

Requirements

• Possession of a master’s degree from an accredited college or university with a major in Business Administration, Health Care Administration, Public Administration, Public Health, or a closely related field.
• Five (5) years of progressively responsible professional experience in health care administration, health plan operations, or a closely related field, including at least two (2) years in a management or supervisory capacity.
• Possession of a Bachelor’s degree from an accredited college or university and two (2) additional years of qualifying experience may be substituted for the Master’s degree.
• Two (2) additional years of qualifying experience may be substituted for academic major concentration.

Nice To Haves

• Experienced in Managed Care Leadership: Brings extensive experience leading health plan claims operations within a managed care environment, including responsibility for complex, high-volume systems
• Knowledgeable in Medicaid and Medicare: Demonstrates deep understanding of program requirements, claims payment policy, audits, and regulatory oversight
• A Strategic Thinker: Able to translate regulatory requirements and organizational priorities into sustainable operational strategies
• A Strong Communicator: Clearly conveys complex claims, financial, and compliance issues to executive leadership, staff, providers, and external partners
• Solution-Oriented: Proactively identifies operational risks and implements improvements that enhance accuracy, timeliness, and provider experience
• Professional and Collaborative: Builds strong relationships across finance, compliance, IT, utilization management, and external vendors
• Discreet and Judicious: Exercises sound judgment when managing confidential, sensitive, and high-risk matters
• Delivering Results: Achieves organizational and regulatory goals through strong operational leadership and accountability
• Legal & Regulatory Navigation: Interprets and applies complex laws, regulations, and guidance
• Ownership & Accountability: Takes responsibility for outcomes and ensuring follow-through across teams
• Technology Leadership: Guides the effective use of claims and payment systems to support operational performance, data integrity, and regulatory requirements, while partnering with IT on system enhancements and upgrades
• Oral Communication: Effectively communicates complex information to executive and external audiences

Responsibilities

• Providing leadership and oversight of all CCHP claims operations, including claims adjudication, adjustments, payment integrity, and recovery activities
• Directing, coaching, and evaluating managers and supervisors responsible for daily claims operations
• Overseeing clearinghouses and other claims-related vendors, including contract performance and issue resolution
• Directing the use and optimization of Epic Tapestry for claims adjudication, payment rules, edits, and reporting, and ensuring system changes are appropriately tested, documented, and implemented
• Ensuring full compliance with federal, state, and local regulations, including DHCS, DMHC, and CMS requirements
• Establishing and monitoring key performance indicators related to claims timeliness, accuracy, financial controls, and regulatory compliance
• Serving as the primary liaison for claims-related matters with providers, county partners, auditors, and regulatory agencies
• Identifying operational risks, audit findings, and systemic issues, and ensuring timely corrective action and reporting to executive leadership

What This Job Offers

• Job Type: Full-time
• Career Level: Manager