Director of Claims- Bakersfield 1.1
About The Position
The Director of Claims provides strategic leadership and operational oversight for the Claims Department, ensuring the delivery of accurate, timely, and compliant claims and encounter processing across all product lines. This role is responsible for setting the vision and direction of the department, driving process optimization, and implementing scalable solutions that enhance productivity, quality, and financial performance. The Director partners closely with executive leadership, including the Chief Operations Officer, and cross-functional departments such as Enrollment, IT, and Finance to ensure seamless system configuration, accurate adjudication, and alignment with organizational goals. This position plays a critical role in advancing automation, strengthening compliance, and fostering a high-performing, accountable team culture.
Requirements
- Minimum of 5–8 years of progressive experience in claims operations within a managed care or IPA/group setting preferred.
- Minimum of 5 years of leadership experience at a manager level or above, with demonstrated success leading teams and driving operational outcomes preferred.
- Bachelor’s degree in Healthcare Administration, Business Administration, or a related field required; Master’s degree preferred.
- Extensive knowledge of professional and institutional claims processing, including COB, TPL, and Workers’ Compensation.
- Strong expertise in fee schedules and pricing methodologies across inpatient, outpatient, ancillary, and professional claims.
- In-depth knowledge of CMS, DMHC, and DHS regulations and compliance requirements.
- Proven experience with claims systems, workflow automation, and process optimization.
- Strong understanding of provider contracts and financial responsibility structures within health plans.
- Demonstrated ability to lead large-scale initiatives, manage competing priorities, and influence cross-functional stakeholders.
- Exceptional analytical, problem-solving, and decision-making skills.
- Excellent communication and executive presentation skills.
- Advanced proficiency in Microsoft Office applications, particularly Excel.
Responsibilities
- Provide strategic direction and oversight of all claims operations, including inventory management, adjudication, and encounter submission.
- Establish and drive departmental goals aligned with organizational objectives, focusing on operational excellence, scalability, and continuous improvement.
- Lead the design, development, and optimization of claims workflows, policies, and procedures to improve efficiency and accuracy.
- Ensure compliance with all federal, state, and regulatory requirements, including CMS, DMHC, and DHS standards, across all product lines.
- Oversee productivity and quality metrics, ensuring claims are processed within established timeliness and accuracy standards.
- Analyze operational performance data and trends to identify risks, gaps, and opportunities for process improvement and cost containment.
- Collaborate with executive leadership to support strategic initiatives, including system implementations, vendor partnerships, and platform enhancements (e.g., EZ-Cap upgrades).
- Partner with Enrollment and IT teams to ensure accurate system configuration and claims adjudication integrity.
- Lead the development and implementation of automation strategies and system enhancements to reduce errors and improve throughput.
- Ensure appropriate allocation and utilization of human and technological resources to meet performance and budgetary targets.
- Develop and implement training strategies and succession planning initiatives to build organizational capability and leadership bench strength.
- Oversee departmental compliance audits and ensure readiness for internal and external reviews.
- Participate in organizational planning, including strategic planning, goal setting, and performance evaluation.
- Serve as a key liaison across departments to resolve workflow, system, and operational challenges.
- Provide regular reporting and executive-level insights on departmental performance, risks, and key initiatives.
- Foster a culture of accountability, collaboration, and continuous improvement within the claims team.
- Lead, mentor, and develop management staff; oversee recruiting, hiring, and performance management processes for the department.
- Other duties as assigned.
Benefits
- Medical
- Dental
- Vision
- Paid Time Off (PTO)
- Floating Holiday
- Simple IRA Plan with a 3% Employer Contribution
- Employer Paid Life Insurance
- Employee Assistance Program
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What This Job Offers
Job Type
Full-time
Career Level
Manager
Number of Employees
1-10 employees
