Claims Operations Manager
About The Position
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. The Claims Operations Manager will lead the Claims Operations Unit within the Claims Department. The role involves managing and leading the unit, acting as a subject matter expert, and providing guidance on claims operations functions and departmental operations. It also includes providing management oversight for planning, leading, and implementing claims operations activities such as audits, root-cause analysis, quality reporting, compliance coordination, and governance of claims policies and procedures. Additionally, the position oversees the full Provider Dispute Resolution (PDR) lifecycle and manages, supervises, mentors, and trains assigned staff.
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
- Must reside in California upon hire
- Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship.
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
Benefits
- Medical, Dental and Vision Plans
- Ample Paid Time Off
- 12 Paid Holidays per year
- 401(a) Retirement Plan
- 457 Deferred Compensation Plan
- Robust Health and Wellness Program
- Onsite EV Charging Stations
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What This Job Offers
Job Type
Full-time
Career Level
Manager
