Director - Claims

Astrana Health, Inc.•Monterey Park, CA

3d•Hybrid

About The Position

The Director - Claims will be responsible for overseeing the end-to-end claims management process, ensuring accuracy, efficiency, and compliance with regulatory standards. This role involves leading a team of claims professionals, optimizing workflows, and driving strategic initiatives to improve claims operations. The ideal candidate is an experienced leader with a deep understanding of healthcare claims, payer-provider relationships, and a commitment to delivering exceptional service.

Requirements

Bachelor’s degree in healthcare administration, business, or a related field
8+ years of progressive responsibility, preferably in a managed care setting Knowledge of DMHC, DHS, and CMS regulations and guidelines
Proficient in knowledge of CPT, HCPCS, ICD-10, Strong knowledge of MSO operations, healthcare reimbursement models, and payer/provider dynamics
Expertise in claims processing systems and technologies (e.g., EHR, claims adjudication software)
In-depth understanding of healthcare regulations, including HIPAA and CMS guidelines
Prior experience working in managed care/IPA setting

Nice To Haves

You have a master's degree
Have EZ-CAP software experience

Responsibilities

Provide strategic direction for the claims department, aligning operations with company goals and regulatory requirements
Lead, mentor, and develop a high-performing claims management team
Collaborate with executive leadership to establish and achieve claims-related KPIs and financial targets
Identify the root cause of any operational weaknesses and implement the best solution
Serve as a thought partner to internal and external stakeholders to achieve mutual goals
Oversee end-to-end claims operations, claims processing, adjudication, and resolution to ensure timeliness, accuracy, and compliance
Develop, implement, review dashboards, reports, policies, procedures, and workflows to optimize efficiency and mitigate errors
Team accountability for areas such as – timeliness reporting to the health plans, encounter reports, weekly inventory and workflow reports, and IPA claims summary report for board meetings
Monitor and address claim denial trends, providing actionable insights and corrective strategies
Manage relationships with payers, third-party administrators, and other key stakeholders
Ensure compliance with state, federal, and industry regulations, including HIPAA and CMS guidelines
Prepare and present regular reports on claims performance, trends, and department metrics
Conduct audits and reviews to maintain high standards of accuracy and compliance