Director, HMO Claims Services

Scripps Health • San Diego, CA

2d • Hybrid

About The Position

This is a full-time leadership position, eligible for Scripps Health annual Management Incentive Compensation Plan. This position is partial remote and located in San Diego and does require residence in San Diego. The weekly schedule will be 2 days in the office and 3 days remote.

About Scripps Health:
Founded in 1924, Scripps Health is a $5 billion, private nonprofit health system based in San Diego, founded in 1924 by philanthropist Ellen Browning Scripps. Serving over 600,000 patients annually, it operates five acute-care hospitals, 30 outpatient centers, home health services, and a wide physician network of 3,000 affiliated doctors and 17,800 employees. Recognized nationally for excellence, Scripps has earned top rankings from U.S. News & World Report, Fortune, Newsweek, and Becker’s Healthcare, and maintains an AA rating with a stable outlook from S&P Global Ratings due to its strong leadership and financial performance.

The Director of HMO Payment (Claims) Services for Scripps Health Plan provides strategic and operational leadership for the claims payment function, ensuring the accurate, timely, and compliant processing and payment of professional and institutional provider claims.

This leader is responsible for optimizing claims operations, driving successful Plan and DMHC audit performance, overseeing staff education and training, and managing the PDR process. The Director will partner closely with MSO and Plan departments to ensure effective workflows, resolve operational issues, and promote seamless coordination across the organization.

As a subject matter expert, this individual will play a key role in Epic/Tapestry system implementations, workflow optimization, reporting, and data-driven performance management, including the development and monitoring of claims KPIs.

Please note: This is a health plan claims payment/operations leadership position—not a revenue cycle, hospital billing, or accounts receivable role.

Successful candidate will demonstrate:
Claims automation optimization.
Claims recovery.
Epic/Tapestry expertise including workbench and WebI reporting.
Reporting and KPI development and management.
Experience with mailroom.
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Requirements

• 8 years’ experience in managed care claims, 3 of which in leadership.
• Expertise is California DMHC claims regulations, NCQA regulations and health Plan experience.
• Strong technical aptitude for computer systems and databases.

Nice To Haves

• Claims automation optimization.
• Claims recovery.
• Epic/Tapestry expertise including workbench and WebI reporting.
• Reporting and KPI development and management.
• Experience with mailroom.
• Bachelor’s degree in related field.
• Epic Tapestry experience.
• Strong reporting experience, specifically Epic Workbench and WebI.
• Understanding of institutional and professional claims, implications and codes.
• Experience with DMHC audits, health plan audits, CPT and ENM coding
• Mailroom experience.

Responsibilities

• Provides strategic and operational leadership for the claims payment function, ensuring the accurate, timely, and compliant processing and payment of professional and institutional provider claims.
• Optimizing claims operations.
• Driving successful Plan and DMHC audit performance.
• Overseeing staff education and training.
• Managing the PDR process.
• Partnering closely with MSO and Plan departments to ensure effective workflows, resolve operational issues, and promote seamless coordination across the organization.
• Playing a key role in Epic/Tapestry system implementations, workflow optimization, reporting, and data-driven performance management, including the development and monitoring of claims KPIs.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: Associate degree