Claims Risk Manager Jobs in Westminster, CA (NOW HIRING)

Position Summary

The Provider Configuration Supervisor is responsible for leading and overseeing all day-to-day provider and contract configuration activities within the claims adjudication system (EZCAP) for a fully delegated IPA/MSO operating under Full-Risk Medicare Advantage and Value-Based Care contracts.

This role ensures that providers, facilities, contracts, fee schedules, DOFRs (Delegated Organization Financial Responsibility), benefit configurations, and claims payment rules are configured accurately, timely, and in alignment with executed contracts, delegation agreements, and financial models. The Supervisor leads configuration analysts, enforces configuration standards, mitigates downstream claims risk, and ensures claims are clean, payable, and audit-defensible.

This is a mission-critical role: configuration errors directly result in incorrect provider payments, financial leakage, disputes, regulatory exposure, and provider dissatisfaction.

Core Accountability

Own the integrity, accuracy, and operational readiness of all provider and contract configuration within EZCAP to support clean claims adjudication under full-risk, delegated value-based contracts.

Key Responsibilities

1. Claims System Configuration Leadership (EZCAP)

• Lead and supervise all provider, contract, and financial configuration activities within EZCAP.
• Ensure accurate setup and maintenance of:
  • Providers (PCPs, Specialists, Facilities, Ancillaries)
  • Provider hierarchies and affiliations (TIN, billing NPI, rendering NPI)
  • Payor contracts and sub-contracts
  • DOFRs (Delegated Organization Financial Responsibility)
  • Provider Fee Schedules / Fee Sets
  • Capitation arrangements
  • Risk pools, withholds, and bonus configurations
  • Global and partial delegation logic
• Own configuration logic that determines who pays whom, how much, and under what rules.

2. DOFR & Financial Responsibility Configuration

• Configure and maintain DOFR structures reflecting:
  • IPA vs Health Plan responsibility
  • PCP vs Specialist responsibility
  • In-network vs out-of-network scenarios
  • Facility vs professional claim logic
• Ensure DOFR logic aligns with:
  • Delegation agreements
  • Health plan contracts
  • Provider contracts
  • Internal financial models and actuarial assumptions
• Partner with Finance and Actuarial teams to validate financial accuracy.

3. Provider Fee Set & Contract Configuration

• Oversee configuration of:
  • Fee-for-service schedules
  • Case rates
  • Percent-of-charge models
  • Flat fee arrangements
  • Custom carve-outs
• Ensure fee sets align precisely with executed provider contracts and amendments.
• Manage retroactive configuration changes with appropriate impact analysis and documentation.

4. Team Leadership & Supervision

• Supervise configuration analysts and specialists including:
  • Work assignment and prioritization
  • Training and onboarding
  • Quality control and peer review
  • Performance management
• Establish configuration standards, SOPs, and naming conventions.
• Serve as escalation point for complex configuration scenarios and claims issues.

5. Cross-Functional Coordination

• Partner closely with:
  • Credentialing (provider readiness)
  • Contracting (interpretation of provider and payor contracts)
  • Claims Operations (claims outcomes and issue resolution)
  • Finance / Actuarial (payment accuracy and financial modeling)
  • Provider Disputes (root cause resolution)
  • Compliance (audit and delegation oversight)
• Translate contract language into executable system logic.

6. Claims Readiness & Issue Resolution

• Support claims production by ensuring configuration is:
  • Complete prior to provider go-live
  • Tested and validated
• Participate in claims triage for:
  • Underpayments
  • Overpayments
  • Misrouting of financial responsibility
• Perform root-cause analysis of configuration-driven claims defects and implement corrective actions.

7. Audit, Compliance & Delegation Readiness

• Ensure configuration is audit-defensible for:
  • Health plan delegation audits
  • Internal compliance reviews
  • CMS or regulatory inquiries
• Maintain documentation for configuration decisions, overrides, and exceptions.
• Support Corrective Action Plans (CAPs) related to configuration findings.

8. Change Management & Configuration Governance

• Establish and enforce configuration change control processes.
• Review and approve:
  • New provider builds
  • Contract amendments
  • Retroactive configuration changes
• Maintain configuration logs and version tracking.
• Ensure changes are communicated to downstream teams (claims, finance, provider relations).

9. Reporting & Performance Oversight

• Track and report configuration KPIs including:
  • Provider build turnaround time
  • Contract configuration cycle time
  • Configuration defect rate
  • Claims rework attributable to configuration
• Provide regular operational updates to the Senior Director of MSO Operations.

Qualifications

Education

• Bachelor’s degree in Healthcare Administration, Business, Finance, Information Systems, or related field preferred.
• Equivalent experience in delegated claims configuration accepted.

Experience

• 6+ years of healthcare claims configuration experience in an IPA, MSO, or health plan.
• 3+ years of hands-on EZCAP configuration experience required.
• 2+ years of supervisory or lead experience strongly preferred.
• Deep experience in delegated, full-risk Medicare Advantage environments required.
• Proven experience configuring DOFRs, provider fee sets, and complex payment logic.

Technical Expertise

• Advanced EZCAP configuration knowledge:
  • Provider builds
  • Contract loading
  • DOFR logic
  • Fee schedules
• Strong understanding of:
  • Medicare Advantage delegation models
  • Claims adjudication workflows
  • Provider payment methodologies
• Advanced Excel and analytical skills.

Core Competencies

• Exceptional attention to detail
• Strong systems and financial logic thinking
• Ability to interpret contracts into executable system rules
• Leadership and coaching capability
• High accountability and ownership mindset
• Strong cross-functional communication
• Comfort operating in high-risk, audit-exposed environments

Key Performance Indicators (KPIs)

• Claims paid correctly on first pass
• Configuration error rate
• Provider build and contract setup turnaround time
• Reduction in configuration-related disputes
• Audit findings related to configuration
• Team productivity and quality metrics

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.