Sr Director, Claims Operations & Provider Configuration

Advanced Medical Management • Long Beach, CA

16d

About The Position

We are a high-performing Managed Services Organization (MSO) supporting a Primary Care Independent Practice Association (IPA) operating under Full-Risk Medicare Advantage Value-Based Care contracts. Our organization partners with primary care providers to deliver high-quality, patient-centered care while managing total cost of care, quality outcomes, and regulatory compliance.

As a fully delegated MSO, we oversee claims adjudication, provider configuration, payment integrity, and operational enablement at scale. Our success depends on disciplined operations, strong provider alignment, and flawless execution across claims, configuration, eligibility, and payment workflows.

Position Summary

The Senior Director of Claims Operations & Provider Configuration is a senior operational leader responsible for end-to-end claims execution, provider setup/configuration, and claims system integrity across a fully delegated, full-risk Medicare Advantage environment.

This role is accountable for ensuring that providers are configured correctly, claims adjudicate accurately, capitation and risk arrangements are honored, and downstream financial, clinical, and regulatory impacts are tightly controlled.

Reporting to the VP of MSO Operations, this role serves as the day-to-day executive owner of claims operations and provider configuration, translating strategic direction into scalable execution. The Senior Director will lead multiple teams, own critical KPIs, partner cross-functionally with Finance, IT, Provider Engagement, Compliance, and Health Plans, and ensure operational readiness for growth, audits, and new market or payor expansion.

Requirements

• Bachelor’s degree in Healthcare Administration, Business, Finance, or related field
• 10+ years of healthcare operations experience, with significant depth in claims operations
• 5+ years in a senior leadership role managing managers and complex teams
• Demonstrated experience in fully delegated, full-risk Medicare Advantage environments
• Deep understanding of: Claims adjudication logic Provider configuration and fee schedules Delegation models Medicare Advantage regulations
• Proven ability to operate at scale in a high-volume, high-accountability environment

Nice To Haves

• Master’s degree (MHA, MBA, or similar)
• Experience supporting: Multi-state IPA/MSO operations Rapid growth or M&A integrations
• Strong familiarity with claims platforms, configuration engines, and analytics tools
• Lean, Six Sigma, or formal process improvement training

Responsibilities

• Claims Operations Leadership (Full-Risk, Fully Delegated Environment)
• Provider Configuration & Claims System Integrity
• Financial Stewardship & Payment Integrity
• Performance Management & KPIs
• Compliance, Delegation & Regulatory Oversight
• Team Leadership & Development
• Scalability, Growth & Transformation

Benefits

• Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.
• Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.
• Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
• Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.
• Career Development: Tuition reimbursement to support your education and growth.

What This Job Offers

• Job Type: Full-time
• Career Level: Executive