Director Re Logic Jobs (NOW HIRING)

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.