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Claims Operations Jobs in California (NOW HIRING)

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Claims Operations information

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$12

$23

$42

How much do claims operations jobs pay per hour?

As of Aug 21, 2026, the average hourly pay for claims operations in California is $23.19, according to ZipRecruiter salary data. Most workers in this role earn between $17.31 and $25.38 per hour, depending on experience, location, and employer.

What is claims operations?

Claims Operations refers to the processes and teams responsible for handling, processing, and managing insurance claims from start to finish. This includes reviewing claims submissions, verifying information, coordinating investigations, and ensuring that claims are settled efficiently and accurately. Claims Operations professionals work to streamline workflows, comply with regulations, and deliver a positive experience for policyholders. Their role is essential in preventing fraud, reducing costs, and maintaining customer satisfaction within an insurance company.

What are the key skills and qualifications needed to thrive in claims operations?

To thrive in Claims Operations, you need strong analytical abilities, attention to detail, and a background in insurance, finance, or a related field. Familiarity with claims management systems, regulatory compliance tools, and industry certifications such as AIC (Associate in Claims) is often required. Excellent communication, problem-solving skills, and adaptability help professionals handle complex claims and interact effectively with clients and stakeholders. These competencies are crucial for ensuring accurate, timely claims processing and maintaining customer satisfaction.

What are some common challenges faced in a claims operations role and how can they be managed?

Professionals in Claims Operations often encounter challenges such as managing high volumes of claims, ensuring accuracy under tight deadlines, and navigating complex regulatory requirements. To manage these effectively, strong organizational skills, attention to detail, and familiarity with claims processing software are essential. Many teams use workflow automation and regular training sessions to stay updated on procedures and compliance standards, which helps streamline operations and reduce errors. Building strong communication skills also aids in collaborating with adjusters, underwriters, and customers to resolve issues efficiently.

What is the difference between Claims Operations vs Claims Adjuster?

AspectClaims OperationsClaims Adjuster
Primary RoleOversees claims processing, manages teams, and ensures compliance across claims functions.Evaluates individual claims, investigates damages, and determines settlement amounts.
Required CredentialsTypically requires claims handling certifications, insurance licenses, and management experience.Requires adjuster licenses, claims handling certifications, and knowledge of insurance policies.
Work EnvironmentOffice-based, team management, and coordination with various departments.Fieldwork and office work, direct interaction with claimants and vendors.
Industry UsageCommonly used in insurance companies for claims processing departments.Used by insurance carriers for claim evaluation and settlement.

Claims Operations focuses on managing the overall claims process and team coordination, while Claims Adjusters handle individual claim evaluations and settlements. Both roles require insurance-related certifications and are integral to the insurance industry, but they differ in scope and daily responsibilities.

Is claims processing a stressful job?

Claims processing is a core part of claims operations and can be stressful due to tight deadlines, high workload, and the need for accuracy. Employees often manage multiple claims simultaneously and must pay close attention to detail, which can contribute to job stress, especially during busy periods or complex cases.

What are the most commonly searched types of Claims Operations jobs in California?

The most popular types of Claims Operations jobs in California are:

What are popular job titles related to Claims Operations jobs in California?

For Claims Operations jobs in California, the most frequently searched job titles are:

What job categories do people searching Claims Operations jobs in California look for?

The top searched job categories for Claims Operations jobs in California are:

Claims Operations jobs near you
Infographic showing various Claims Operations job openings in California as of August 2026, with employment types broken down into 1% As Needed, 86% Full Time, 9% Part Time, 1% Temporary, 2% Contract, and 1% Nights. Highlights an 93% Physical, 3% Hybrid, and 4% Remote job distribution, with an average salary of $48,245 per year, or $23.2 per hour.

Sr Director, Of MSO & Provider Configuration

Advanced Medical Management

Long Beach, CA • On-site

$195K - $225K/yr

Other

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 24 days ago

Job description


Position Overview

We are seeking a highly technical, hands-on operational executive to serve as our Senior Director of MSO – Claims Operations & Provider Configuration. This position requires candidates to be based in Southern California.

This role requires a true Subject Matter Expert (SME) with deep, end-to-end expertise in claims operations within a fully delegated, full-risk Medicare Advantage environment. Direct, hands-on EZCAP experience is required.

This is not a high-level oversight position. The ideal candidate can speak in detail about adjudication logic, denial trends, provider configuration dependencies, and the operational issues they have personally resolved. This leader will own claims accuracy, configuration integrity, financial alignment, and measurable KPI performance across the MSO.

Key Responsibilities

End-to-End Claims Operations Ownership

  • Oversee the full claims lifecycle: intake, validation, adjudication, pricing, payment, adjustments, reprocessing, and reporting
  • Ensure high first-pass adjudication rates and CMS-compliant turnaround times
  • Monitor denial trends and implement structured root cause corrective actions
  • Serve as executive escalation point for complex claims and systemic issues
  • Align claims operations with capitation models, IBNR, MLR, and risk pool performance

Provider Configuration & EZCAP Governance

  • Own provider configuration within EZCAP, including:
    • Demographics
    • Contract terms
    • Fee schedules
    • Risk arrangements
    • Delegation indicators
    • Effective dates and terminations
  • Establish configuration QA, validation, and change control governance
  • Prevent mispricing, claims leakage, and downstream financial exposure
  • Ensure system integrity across payor transitions, growth, and new market expansion

Performance Management & Operational Improvement

  • Improve measurable KPIs including:
    • First-pass adjudication rate
    • Claims accuracy rate
    • Turnaround time (clean vs. non-clean)
    • Rework percentage
    • Configuration error rate
  • Conduct root cause analysis on systemic operational issues
  • Design and operationalize scalable, sustainable solutions
  • Build dashboards and performance reporting for executive leadership

Financial & Regulatory Stewardship

  • Ensure claims payments align with contract terms and value-based arrangements
  • Mitigate overpayment, underpayment, and compliance risk
  • Lead audit readiness for CMS and health plan delegation oversight
  • Partner with Finance and Actuarial on trend analysis and cost variance drivers

Leadership & Team Development

  • Lead managers and SMEs across claims and configuration teams
  • Build a metrics-driven, high-accountability culture
  • Coach leaders on technical problem-solving and escalation management
  • Ensure operational readiness for audits, system upgrades, and organizational growth

Required Qualifications

  • Must be based in Southern California
  • 10+ years of healthcare claims operations experience
  • 5+ years in senior leadership managing managers and complex teams
  • Direct, hands-on EZCAP experience (required)
  • Demonstrated expertise in:
    • Claims adjudication logic
    • Provider configuration and fee schedules
    • Delegated Medicare Advantage models
    • CMS regulatory requirements
  • Proven experience in a fully delegated, full-risk Medicare Advantage environment
  • Strong root cause analysis and process optimization background
  • Documented success improving claims KPIs and reducing operational leakage

Preferred Qualifications

  • Master’s degree (MBA, MHA, or related field)
  • Multi-state IPA/MSO experience
  • Experience supporting rapid growth, new market expansion, or M&A integrations
  • Background in operational automation or system optimization initiatives

Core Competencies

  • Deep technical and operational expertise (not surface-level oversight)
  • Financial and analytical acumen
  • Strong executive judgment and escalation management
  • Ability to translate complexity into scalable execution
  • Calm, decisive leadership under pressure

AMM BENEFITS

When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:

  • 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.