Claims Director

Central Coast Salary Range

$174,547 - $261,821

*While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.*

Job Summary

This position directs the functions of the Claims Department, providing strategic, operational, and transformational leadership for claims adjudication, claims support services, encounter data, and overall claims operations. The Director is responsible for optimizing end-to-end claims processes, leveraging technology and automation, and driving continuous improvement initiatives that enhance efficiency, accuracy, regulatory compliance, provider satisfaction, and organizational performance.

The Claims Director is responsible for the overall staffing, planning, fiscal management, administration, and operation of all claims functions, programs and activities. The Director ensures that all claims functions meet or exceed regulatory, compliance, and timely service requirements, and that customer service and support is of the highest quality. The Director ensures claims are processed accurately, efficiently, and in compliance with applicable state and federal regulations through effective operational oversight, quality standards, and performance management. This role leads enterprise claims transformation initiatives that improve performance, reduce administrative burden, and increase automation.

The Director provides leadership for establishing and optimizing production workflows, quality standards, operating policies, procedures, and claims processing guidelines. The role collaborates across the organization to ensure claims operations support business, financial, operational, and reporting objectives while advancing CenCal Health's strategic goals.

Serves as a member of CenCal Health’s senior leadership team and collaborates with the other departments to develop and implement strategies which support the provider network. Develops strong relationships with internal and external partners and implements efficient and effective operational processes that enhance organizational performance.

This position reports directly to the Chief Operating Officer in the Operations Division and is responsible for the complete oversight of the Claims Department.

Duties & Responsibilities

• Provide leadership to the Claims Department and establish objectives which ensure that the department goals and objectives are met and that customer service to the provider network is at the forefront of all department operations.
• Supervise directly reporting staff.
• Oversee the interpretation and implementation of State and Federal statutes, regulations and mandates (including NCQA, HEDIS, HIPAA, Knox Keene, DHCS, DMHC, CMS) pertinent to claims processing function, while improving claims processes to yield operational efficiencies.
• Serve as the subject matter expert for Medicare claims operations and payment requirements, ensuring operational readiness, compliance, and scalability for existing and future Medicare products and programs.
• Ensure the timely, accurate configuration of the claims system including ongoing auditing to identify and implement areas for improvement.
• Oversee the timely and accurate implementation of benefits, provider payment rate updates, and dispute/appeal handling processes.
• Create updated Department policies and procedures as necessary.
• Ensure the efficient, timely, and accurate adjudication of claims; revising operating workflows, and other necessary changes to effectively implement changing policies and procedures.
• Lead continuous process improvement initiatives utilizing data analytics, workflow redesign, automation, and best practices to improve productivity, reduce manual effort, and enhance claims accuracy and turnaround times.
• Develop and execute a long-term operational strategy for claims modernization, including implementation of automation tools, artificial intelligence-enabled workflows where appropriate, system enhancements, and streamlined business processes.
• Enhance operational performance metrics and dashboards to monitor productivity, quality, and service outcomes; use data to drive decision-making and resource allocation.
• Collaborate with Configuration on the timely, accurate configuration and optimization of the claims platform, ensuring technology solutions support efficient workflows, regulatory compliance, payment integrity, and organizational objectives.
• Develop, implement, and monitor programs and procedures to assure the efficient and timely submission of accurate encounter data.
• Oversee the volume and financial impact of pended claims, and status of subsystems maintained by Claims staff
• Ensure staff is advised of all procedural changes in a timely manner, and that such changes are implemented promptly and effectively.
• Direct the claims service functions and claims mailroom to ensure that responses to provider inquiries, disputes or appeals, and internal inquiries are resolved accurately, promptly and with a high level of customer service.
• Ensure responsive and proactive individual and group training for hospitals and other providers on claims processes in coordination with the Provider Services or Provider Relations Department.
• Implement any policy or regulatory changes in a timely and compliant manner.
• Provide monthly Board reports and statistics related to claims adjudication or service activities; ensure accuracy of statistical data submitted.
• Collaborate with Compliance, Legal, IT, Provider Services, Health Services, Configuration, and other necessary departments to ensure that the claims payment system is configured and maintained appropriately to support accurate claims processing and adhere to state and federal regulatory requirements.
• Manage vendors used to support claims processing and auditing including, but not limited to, reviewing contracts, establishing and managing performance expectations, periodically surveying market for alternative vendors and participate in due diligence and annual delegation audits.
• Ensure timely recruitment, retention, training and development of qualified claims staff.
• Oversee any delegated functions related to claims, including ongoing monitoring, reporting, and corrective action, as needed.
• Develop and cultivate a culture to promote the best workplace experience for department employees.
• Contributes as a key member of the Senior Leadership Team and committees, addressing the strategic goals of the department and organization.
• Delegates and monitors progress on achieving key metrics, key initiatives and project goals, staff productivity, expense management.
• Other projects and duties as assigned.

Knowledge/Skills/Abilities

Required

• Demonstrated ability to lead operational transformation initiatives and implement sustainable process improvement strategies.
• Strong knowledge of automation technologies, workflow optimization methodologies, business process redesign, and operational efficiency best practices.
• Demonstrated ability to leverage data analytics and performance metrics to drive operational improvements and informed decision-making.
• Strong understanding of claims system capabilities, technology solutions, and digital transformation strategies within a managed care environment.
• Excellent leadership skills, communication skills, strategic thinking and proven ability to build strong interpersonal relationships.
• Strong ability to build key relationships at all levels of the organization.
• Strong written and oral communication skills.
• Strong ability to solve unique and complex problems that have a broad impact on the organization.
• Thorough knowledge of core operation functions of a managed care organization.
• Thorough knowledge of California managed care regulations and mandates.
• Strong ability to forecast and manage project budgets.
• Strong organization, time management and project management skills and multi-tasking abilities.
• Thorough knowledge of analytics and problem-solving skills with the ability to formulate and communicate recommendations for improvement.
• Thorough knowledge of continuous quality improvement techniques.
• Strong ability to demonstrate flexibility to changes and response to new ideas and approaches.
• Strong ability to achieve prompt resolution to problems and issues with provider partners.
• Strong ability to communicate with the public and convey detailed instructions to staff accurately.

Education & Experience

Required

• Five (5) years of management level experience as a department Director or equivalent in a healthcare environment
• Bachelor's degree AND five (5) years of recent management experience in medical claims operations ORany equivalent combination of education, training and experience. Health maintenance organization (HMO), Medi-Cal and Medicare claims operations experience is required.
• Extensive health plan claims operations experience is required, including significant Medicare and Medi-Cal claims leadership experience. Demonstrated success leading Medicare claims operations, implementing operational improvements, modernizing workflows, and achieving measurable gains in efficiency, quality, compliance, and service performance.
• Knowledge of: managed care contracting methods; health plan core transaction systems; organization and staffing of the medical claims and claims service functions; provider billing and reimbursement methodologies; policies and procedures utilized in medical claims processing; supervisory and staff development techniques; medical economics; fraud, waste and abuse detection and prevention, performance and workflow improvement, NCQA accreditation and HIPAA complaint claim coding guidelines.
• Extensive knowledge of Medicaid, Medicare, and Commercial health plan operations, reimbursement methodologies, payment integrity programs, encounter data requirements, and regulatory frameworks.
• Proficient in Microsoft Office suite and the graphical display of complex financial and operational data.