Claims Operations Jobs in California (NOW HIRING)

Department: Ops - Claims Ops

Employment Type: Full Time

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Reporting To: Linda Haston

Compensation: $115,441 - $148,149 / year

The Senior Claims Manager, Claims Delegation Oversight, is responsible for the management and oversight of all Claims Delegation Audits, including health plan and governing agencies audits, i.e., DMHC, CMS, and DHCS. This role will be responsible for the development and execution of department strategies, overall Audit program, Audit process optimization, and management, identifying and leveraging technology and data to improve the quality and minimizing process cost of Claims. The position alongside the leadership team will contribute to driving strategic planning, operational excellence, and accuracy of the claims process and ensure compliance with regulations and contract requirements for Medicare, Commercial Exchange, and Medicaid service lines. This position will contribute and influence overall Claims Delegation Oversight roadmap to ensure Claims Administrations are adhering to regulatory and internal guidelines as they apply to claims processing and adjudication. Working with the Department Director, Senior Manager will collaborate with other Astrana Health departments and personnel to develop strategies to identify, mitigate and optimize operational and financial gaps.

• Develop and implement the operational strategy for driving all external audits for Prospect to ensure audit planning and readiness, successful audit execution and delivery, CAP management, and improve overall audit score
• Lead, monitor, and oversee the end-to-end lifecycle of all external audits, including but not limited to health plan audits, DMHC audits, CMS audits, etc
• Create, monitor, and manage metrics and goals for successful execution and management of all external audits
• Ensure Audit results are clearly tracked, trended, reported, and communicated timely and effectively
• Collaborate with the reporting team to ensure all universe listings are delivered timely and accurately
• Ensure all supporting documents are pulled timely and reviewed thoroughly prior to delivery
• Ensure a pre-audit is conducted for all external audits to gauge the health of an upcoming audit and to assure conformity with the internal health plan and regulatory guidelines and requirements
• Actively engage in Root Cause analysis of deficiencies, and lead efforts in the development and implementation of effective remediation and process improvement solutions
• Collaborate with Claims operations to ensure any issues found as part of the pre-audit are readily remediated, including devising and implementation of root cause and prevention strategy
• Ensure corrective action plan (CAP) management for issues identified as part of all audits performed with clear root cause analysis and prevention plan Ensure all HP reports (scheduled and ad-hoc) are pulled timely and review/approve the accuracy of reports Documentation,

• Review and approve cross-functional/departmental External Audit process documentation, workflows, policies & procedures, Job aids, and standard operating procedures for completeness and accuracy
• Drive and ensure internal process adherence for creating/ maintaining cross-functional/departmental claims processes, workflows, policies, and procedures, job aids, and standard operating procedures
• Ensure adherence to all Legislative, Regulatory, and Contractual requirements
• Review, collaborate, and oversee the Training Plan & Training Strategy for the team, including measuring training effectiveness and remediation strategy
• Identify training needs/ gaps for the team and ensure timely and effective training is imparted to all team members

• Build and maintain productive & collaborative intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting/ Finance, Recovery, Compliance, Configuration, Network Management, IT Ops, etc.) to enable effective and timely problem/improvement identification & resolution and drive operational excellence
• Collaborate with the Claims Operations and Internal Audit Teams to develop a robust external audit strategy, root cause analysis, and prevention plan for any claim-related issues
• Drive and collaborate with the IT & Data Analytics team to create/ develop tools to effectively maintain, update, or revise all scorecards, dashboards, and reports, as necessary
• Collaborate with the Configuration and IT Teams to continuously improve upon system configuration/ rules set up for accurate and effective claims adjudication
• Recommend changes for system design, rules, and workflows affecting Claims processing
• Proactively contributes to Claims testing/ audit strategy development and provides timely feedback based on day-to-day findings
• Conduct special projects, including business analyses, strategic planning, and implementation efforts on new business acquisitions and changing business and organizational requirements
• Develop and execute strategic initiatives and programs to enhance existing functions and develop new processes in support of corporate initiatives and requirements

• Develop goals and objectives for the team and rollout strategy to obtain the established business outcome
• Monitor and track key performance metrics against established goals and coach/ guide the team to achieve success
• Recruit, develop, motivate, and lead the team to continuously improve operational performance
• Other duties as assigned

• Solid understanding of the Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS) rules and regulations governing claims adjudication practices and procedures required
• Detail knowledge and understanding of Industry pricing methodologies, such as Resources-Based Relative Value Scale (RBRVS), Medicare/Medi‑Cal fee schedule, All Patient Refined Diagnosis Related Groups (AP‑DRG), Ambulatory Payment Classifications (APC), etc
• Detail knowledge of Medi‑Cal, Medicare, and Medicaid program guidelines
• Possess working knowledge of NCQA, DHS, and HCFA standards
• Knowledge of medical terminology combined with detailed knowledge and experience with CPT, HCPCS, DRG, REV, OPS, ASC, ICD10, CRVS, RBRVS, CMS, ICE for Health Plan, DMHC and DHS fee schedules and CMS Medicare regulatory agencies, COB and Third‑Party Liability recovery
• Ability to coach and motivate employees to reach and sustain established performance standards and goals
• Ability to direct the work of others and mediate interpersonal encounters with tact and diplomacy, complying with legal guidelines and company policy
• Must have hands‑on claims auditing experience with a clear root cause and prevention plan management
• Must have the ability to analyze and process all levels of claims accurately utilizing advanced level knowledge of CMS and DMHC Regulations
• Must possess the ability to effectively present information and respond to questions from managers, employees, customers
• Must possess advanced reasoning and problem‑solving abilities and planning skills
• Ability to multi-task, prioritize and work in a fast‑paced environment under minimal supervision
• Proficiency in Excel including the ability to create and revise Excel spreadsheets to provide accurate and clear reports
• Bachelor of Science (BS)/Bachelor of Arts (BA) or equivalent education and experience required
• 3+ years of claims administration experience in a Health Plan/IPA/MSO setting
• 3+ years of experience with Health Plan Audits Delegation Audit functions and oversight
• Proven success in improving key performance metrics, including process improvement, cost reduction, and improved efficiency
• Demonstrated leadership skills, ability to coach, mentor, and foster a culture of achievement
• Strong independent decision‑making, influencing, and analytical skills
• Extensive knowledge of claims processing guidelines, including, perspective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi‑Cal guidelines

• 3+ years of experience in people leadership
• EzCap, IDX, Cotiviti Experience, Burgess Experience
• Worked with Clearinghouses like Office Ally
• Experience with managing offshore Vendors
• Core System implementation experience
• Core System configuration experience

• Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis if you live within 35 miles. The office is located at 1600 Corporate Center Dr. Monterey Park, CA 91754
• The national target pay range for this role is $115,440.56 - $148,148.72. Actual compensation will be determined based on geographic location (current or future), experience, and other job‑related factors.

Astrana Health is proud to be an Equal Employment Opportunity and affirmatively action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation.

Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.