Senior Director, Core Administrative Operations

L.A. Care Health Plan•Los Angeles, CA

About The Position

The Senior Director, Core Administrative Operations is responsible for leading and optimizing L.A. Care’s core administrative functions, including Claims Administration, Payment Integrity, Configuration, Electronic Dara Interchange (EDI) and Quality Assurance. This leader ensures standardized, efficient, accurate, and compliant administrative operations that support high-quality service to providers, members, and internal business partners. Steers top-level decision-making and implement initiatives that drive organization's forward. This role drives modernization, operational maturity, and continuous improvement across all core administrative operations, grounded in clear performance expectations, strong governance, and measurable outcomes. The Senior Director collaborates closely with cross functional teams to ensure effective alignment, operational readiness, and sustained performance The Senior Director will oversee a diverse team, ensuring talent development, performance management, and a culture of accountability and operational excellence. This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Develops strategic plans, drives change and influences critical business outcomes.

Requirements

Bachelor's Degree In lieu of degree, equivalent education and/or experience may be considered.
At least 9 years of progressively responsible experience leading large operational teams and multi-functional departments in managed care operations, including Claims Administration, Payment Integrity, Configuration, or similar functions
At least 8 years of management/supervisory experience.
At least 5 years of experience with Payment Integrity operations.
At least 5 years of experience with claims system configuration, technical changes, and operational readiness for products, benefits, and system updates.
Demonstrated successful experience improving operational accuracy, reducing inappropriate payments, and driving regulatory compliance.
At least 5 years of experience supporting regulatory audits.
Strong interpersonal leadership skills and an ability to motivate and develop talent while driving accountability.
Expert knowledge of managed care administrative operations.
Strong strategic, analytical, and financial skills, including the ability to interpret trends, assess risk, and evaluate cost-avoidance opportunities.
Deep understanding of regulatory requirements for Medicaid (Medi-Cal), Medicare, Marketplace, and commercial lines of business.
Proven ability to lead in complex, high-volume, highly regulated environments with competing priorities.
Exceptional communication and stakeholder management skills, with the ability to translate complex concepts into actionable plans.
Exceptional leadership skills and abilities, with demonstrated ability to manage, mentor, and develop multi-level teams.
Ability to design and implement standardized processes, governance models, and operational controls.
Strong skills with claims platforms and analytics/reporting tools.
Proficient with Microsoft Office and data/reporting tools.
High level of organization, planning, prioritization and attention to detail.
Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization.
Demonstrated ability to make sound and timely decisions.
Demonstrated ability to adapt to changing situations and adjust strategies accordingly
Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change.
Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment
Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations.

Nice To Haves

Master's Degree in Business Administration or Related Field
Experience in government-sponsored programs and large regional plans.
Experience with vendor management.
Lean Six Sigma Green Belt
Lean Six Sigma Black Belt

Responsibilities

Translates strategy into disciplined operational execution.
Sets clear expectations, drives cross-functional alignment, and ensures that teams have the tools, data, and governance needed to operate effectively.
Collaborates across multiple administrative functions, ensuring workflows, technical changes, performance indicators, and regulatory requirements are understood, synchronized, and executed consistently.
Anticipates operational challenges, removes barriers, and strengthens end-to-end processes.
Collaborates, plans, proactively problem-solves, leads with transparency, accountability, and focuses on continuous improvement.
Elevates operational reliability and positions the organization for sustained success as systems, products, and regulatory standards evolve.
Leads strategy, operations, and modernization across service areas accuracy, efficiency, and strong control environments.
Establishes and manages operational goals, key performance indicators (KPIs)/objectives and key results (OKRs), dashboards, and other metrics to transparently drive consistent performance and compliance.
Develops and implements standardized workflows, governance structures, and operating procedures.
Fosters a culture of proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.
Directs EDI operations supporting claims submissions, remittance transactions, provider and member exchanges, and other electronic transactions.
Drives automation, data accuracy, and improved electronic submission performance.
Oversees monitoring and timely resolution of technical issues, rejections, and systemic defects.
Ensures high-quality adjudication with strong accuracy, first-pass rates, correct benefit application, and compliance with DHCS, DMHC, CMS, Covered California, and NCQA requirement.
Oversees configuration of benefits, reimbursement logic, pricing methodologies, and adjudication controls.
Collaborates with key stakeholders on prioritization, execution, and validation of configuration updates, system enhancements, and benefit launches.
Leads strategy and operations related to pre-pay controls, cost-avoidance, post-pay recovery, clinical editing, coordination of benefits (COB), overpayments, and third-party liability (TPL)/subrogation.
Partners with cross functional teams to support fraud mitigation and compliance with state and federal requirements.
Improves financial accuracy and reduces inappropriate payments through robust controls and audit-ready processes.
Oversees QA programs across all Core Administrative Operations to ensure ongoing accuracy and compliance.
Strengthens control environments through audits, desktop and other standard operating procedures, and performance monitoring.
Partners with Compliance, Internal Audit, and Enterprise Risk Management on CAPs, audit responses, remediation plans, and sustainability efforts.
Oversees the performance of operational vendors in assigned areas.
Ensures compliance with service level agreements (SLAs), audit standards, quality expectations, and contractual obligations.
Evaluates vendor performance and ensures the implementation of improvements.
Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees.
Manages budgets and resources effectively.
Conducts strategic planning to utilize resources in order to meet current and future departmental and Enterprise-wide goals.
Identifies and actualizes enhancements to support company vision.
Identifies and drives change initiatives.
Collaborates with cross-functional teams to achieve common goals.
Leads discussions on policy operationalization and oversees key policy perspective sharing.
Represents the company or organization in external interactions.
Develops and maintains relationships with key stakeholders.
Develops and implements communication strategies.
Performs other duties as assigned.