Claims Operations Manager

Central California Alliance for Health•Santa Cruz, CA

4d•Hybrid

About The Position

The Alliance has an opportunity to join the Alliance as the Claims Operations Manager leading the Claims Operations Unit within the Claims Department. This position can be located in one of our service counties (Mariposa, Merced, Monterey, Santa Cruz, or San Benito) or remotely in California with expected travel to Alliance service area(s) once a quarter. Must reside in California upon hire. We support the health of our provider relationships. Our teams work closely together to support Alliance members' access to care by ensuring medical services are paid to network providers accurately and on time.

Requirements

Strong understanding of end-to-end claims and PDR operations (volume, accuracy, turnaround)
Uses data and tools to spot trends, make decisions, and actively identify opportunities for automation
Solid experience with Medi-Cal and Medicare, with compliance built into how they work
Focuses on fixing root causes instead of quick fixes
Builds, engages, and supports teams through coaching, accountability, and clear expectations
Brings new ideas, challenges the way things are done, and works closely with other teams to drive better outcomes
Knowledge of: Claims processing functions, including data entry, adjudication, and PDR workflows
Knowledge of: Medi‑Cal, Medicare, and related regulatory requirements that impact claims processing and dispute resolution
Knowledge of: Operational improvement activities, workflow design, and inventory management within a managed care environment
Knowledge of: Medical terminology, billing practices, and coding standards relevant to claims adjudication
Knowledge of: Audit processes, quality standards, and compliance requirements, related to claims operations and dispute workflows
Knowledge of: Research, analysis and reporting methods
Ability to: Train, mentor, supervise, and evaluate the work of staff, promote an atmosphere of teamwork and cooperation, and motivate staff to achieve goals and objectives
Ability to: Develop work plans and workflows and organize and prioritize unit activities to meet performance metrics
Ability to: Organize and prioritize the work of others, delegate effectively, and follow up on work assignments
Ability to: Interpret, apply and explain complex principles, policies, regulations, terms and procedures related to area of assignment
Ability to: Interpret operational data, identify trends, and apply insights, collaborate with Claims Quality on PDR analytics, and identify opportunities for increased auto‑adjudication
Bachelor’s degree in Business, Healthcare Administration, Public Health, or a related field
A minimum of six years of experience in a healthcare or managed care environment which included a minimum of three years of supervisory or management experience in Medi-Cal and Medicare claims operations (a Master’s degree may substitute for two years of the general healthcare or managed care experience); or an equivalent combination of education and experience may be qualifying

Responsibilities

Manages and leads the Claims Operations Unit, acts as a subject matter expert, and provides guidance on claims operations functions and departmental operations
Provides management oversight related to planning, leading, and implementing claims operations activities, including audits, root-cause analysis, quality reporting, compliance coordination, and governance of claims policies and procedures
Oversees the full Provider Dispute Resolution (PDR) lifecycle to ensure accurate, timely, and compliant dispute resolution
Manages, supervises, mentors, and trains assigned staff