Claims Director Jobs in Riverside, CA (NOW HIRING)

Location: Fully onsite in Orange County, CA. Candidates must be able to commute to the office five days per week.

Description:

Our client is seeking an experienced Assistant Director of Claims Operations to support the daily oversight of claims administration for a Medicare Advantage Prescription Drug Plan. This position will assist the Claims Director in ensuring claims are processed accurately, timely, and in compliance with CMS, state, health plan, and internal requirements.

The Assistant Director will provide operational, analytical, administrative, and project support across claims processing, 837 file oversight, payment integrity, issue resolution, provider and IPA coordination, reporting, audit readiness, system initiatives, and process improvement. This position will collaborate closely with Claims Operations, IT, Provider Relations, Compliance, Finance, delegated IPAs, vendors, and other internal stakeholders.

What You Will Do:

• Support the Claims Director in overseeing daily claims operations, including intake, adjudication, pricing, payment, reconciliation, aging inventory, pending claims, and high-dollar claims.
• Oversee the daily receipt, routing, and transmission of incoming and outgoing 837 claim files.
• Work closely with the internal IT team, Delegation group, vendors, and other stakeholders to identify and resolve claim file and processing issues.
• Track, document, escalate, and help resolve complex claims issues involving providers, IPAs, delegated entities, vendors, and internal departments.
• Maintain claims dashboards, issue trackers, reconciliation reports, audit documentation, and operational reports for leadership review.
• Assist with payment integrity reviews, including pricing validation, coding accuracy, authorization linkage, duplicate claim identification, and overpayment or underpayment trend analysis.
• Monitor claims workflows to support compliance with CMS, state, health plan, delegated entity, and internal requirements.
• Prepare claims data, status reports, and supporting documentation for leadership meetings, internal reviews, external audits, and delegated oversight activities.
• Coordinate with Provider Relations, Compliance, Finance, IT, delegated IPAs, and vendors to support timely claims issue resolution.
• Support claims-related system implementations, testing, regulatory updates, process improvements, and departmental projects.
• Draft and coordinate professional communications related to provider inquiries, claims escalations, project updates, and issue resolution.
• Maintain accurate, organized, and audit-ready claims documentation.
• Perform additional duties in support of Claims Department goals and operational priorities.

You Will Be Successful If:

• You demonstrate strong attention to detail, accuracy, and follow-through.
• You understand claims operations and can identify potential processing, payment, or reconciliation issues.
• You use sound judgment and analytical thinking to investigate problems and support timely resolution.
• You communicate clearly and professionally with providers, IPAs, vendors, internal teams, and leadership.
• You can organize competing priorities and consistently meet deadlines in a fast-paced environment.
• You maintain confidentiality and compliance awareness when handling claims, member, provider, and business information.
• You collaborate effectively across departments to support operational alignment, audit readiness, and process improvement.
• You adapt quickly to regulatory changes, system updates, and evolving departmental priorities.

What You Will Bring:

• Bachelor’s degree in business, healthcare administration, finance, public health, or a related field preferred. Equivalent claims operations experience may be considered.
• At least three years of experience within a health plan, managed care organization, Medicare Advantage plan, IPA, TPA, or claims operations environment.
• Experience overseeing daily incoming and outgoing 837 claim files, file routing, and related coordination with IT teams and vendors.
• Working knowledge of claims intake, adjudication, pricing, payment, reconciliation, denials, pending claims, and provider dispute workflows.
• Familiarity with CMS, state, health plan, and delegated entity requirements related to claims administration.
• Experience with claims administration systems, reporting tools, and operational dashboards.
• Proficiency with Microsoft Excel, Outlook, Word, and Teams.
• Strong organizational, analytical, problem-solving, communication, and follow-up skills.
• Ability to manage multiple priorities and confidential information in a fast-paced, onsite environment.
• Medicare Advantage or MAPD claims experience strongly preferred.

About Impresiv Health:

Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.

Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do: provide tangible results that add immediate value at a rate that cannot be beaten. Your success matters, and we know it.

That’s Impresiv!