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<p><b>Salary Range:&nbsp;</b>&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Senior Manager, Claims Administration provides daily operational leadership for enterprise claims adjudication across all lines of business. This position is responsible for ensuring timely, accurate, compliant claim processing through disciplined production management, strong operational controls, and consistent application of claims policies, benefit rules, and contractual requirements.</p><p>The Senior Manager manages a team to deliver predictable throughput, high first-pass accuracy, strong auto-adjudication rates, and consistent cycle-time performance. The position ensures operational readiness for benefit changes, system updates, regulatory modifications, and cross-functional dependencies while continuously improving process quality and reducing rework. The Senior Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.&nbsp; Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.</p><p>This position serves as a subject matter expert in claims adjudication logic, benefit structures, regulatory requirements, billing and coding standards, and provider contract application. The Senior Manager builds a high-performing culture grounded in accuracy, accountability, standardization, continuous improvement, and service excellence.</p><h4>Duties</h4><p>Oversees the daily mechanics of claims production and ensures a controlled, disciplined, and highly reliable operational environment. Responsible for translating enterprise expectations into consistent frontline execution, maintaining a strong control environment, identifying emerging risks quickly, and building upstream partnerships that drive long-term operational maturity. Ensures claims operations are stable, predictable, and aligned to organizational goals.</p><p>Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities. Oversees day-to-day adjudication operations, ensuring a controlled, disciplined, and exceptionally reliable operational environment that is timely, accurate, and high-quality output by L.A. Care staff and external vendors, as necessary. Manages staff to consistently meet or exceed productivity, quality, and inventory performance targets.</p><p>Ensures all claims are processed within Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), Covered California and contractual turnaround requirements.</p><p>Establishes clear routing, triage, and prioritization models to balance workloads and avoid bottlenecks. Promotes operational discipline around standard operating procedures, configuration updates, and quality checkpoints.</p><p>Monitors daily, weekly, and monthly inventory at the claim, queue, and examiner level to anticipate risk and maintain a stable production environment.</p><p>Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/ or executive management to define, prioritize, and develop projects and programs. Conducts structured production meetings with staff to review performance trends, quality indicators, and backlog prevention plans.</p><p>Identifies systemic constraints and drives timely mitigation through collaboration with cross-functional departments and stakeholders.</p><p>Oversees planning and execution during peak periods (open enrollment, benefit year-end/start, provider contract updates).</p><p>Partners with cross-functional departments to monitor and improve first-pass accuracy and aims to remove rework. Ensures examiners correctly apply benefits, coding, pricing, and provider contract terms.</p><p>Identifies claim types or provider groups with chronic accuracy issues and drives upstream corrections.</p><p>Manages initiatives to improve auto-adjudication rates through system corrections, routing refinement, and reduction of manual touchpoints. Ensures examiners receive timely, accurate updates on benefit changes, pricing methods, and new rules.</p><p>Acts as a critical operational partner to Configuration and Information Technology (I.T.) for system updates, benefit loads, provider contract implementations, and code-set changes. Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.</p><p>Participates in User Acceptance Testing (UAT) planning, test case development, operational validation, and go-live readiness for system changes affecting claims.</p><p>Identifies system behavior issues impacting adjudication and ensures prompt ticket creation, escalation, monitoring, and resolution.</p><h4>Duties Continued</h4><p>Ensures examiners receive clear, concise operational guidance tied to configuration updates and policy changes.</p><p>Engages with Enrollment &amp; Eligibility to resolve data discrepancies impacting member benefits or provider assignments.</p><p>Partners with Provider Network on contract load timing, unclear terms, and pricing interpretation issues.</p><p>Coordinates with Utilization Management on authorization-related adjudication issues and utilization policy questions.</p><p>Collaborates with Payment Integrity to leverage findings that require upstream claims-processing adjustments.</p><p>Aligns closely with the senior leadership to ensure seamless handoffs and minimal rework.</p><p>Oversees creation and maintenance of daily production reports, dashboards, and forecasting tools. Uses data to analyze examiner performance, inventory patterns, quality trends, and root-cause drivers of errors. Uses analytical insights to develop operational plans that reduce cycle time, rework, and cost.</p><p>Provides executive-level reporting on throughput, quality, aging, inventory at risk, and operational health.</p><p>Ensures standard operating procedures (SOPs), desktop procedures, workflows, training materials, and job aids are current, accurate, and consistently used across the operation.</p><p>Creates feedback loops with cross-functional departments to update procedures based on new rules or system changes. Ensures staff have clarity on benefit interpretation, contract logic, bundling/unbundling rules, and pricing methodologies.</p><p>Manages staff and the day-to-day activities in the department. Participates in the department budgeting process. Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team. Responsible for overseeing and managing the budgets of their respective departments Builds a culture of rigor, transparency, analytical curiosity, proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.</p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 6 years of experience working in claims operations, provider disputes, adjustments, or related operational functions.</p><p>At least 5 years of experience in leading, supervising and or managing staff.</p><p>Experience in Medicaid, Medicare, and Commercial managed care lines of business.</p><p>Experience interpreting provider contracts, payment methodologies, and managed care benefit structures.</p><p>Experience handling complex claim review, root-cause evaluation, adhering to regulatory TAT requirements, and ensuring accuracy.</p><p>Experience working with Coordination of Benefits (COB) and Third-Party Liability (TPL) claims in a managed care setting.</p><p>Experience leading teams, projects, initiatives, or cross-functional groups.</p><p><strong>Preferred: </strong></p><p>Experience supporting regulatory audits, legal reviews, or corrective action plans.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD)-10, DRG/ Ambulatory Payment Classification (APC), and pricing methodologies.</p><p>Strong understanding of adjudication, coding, pricing, the application of Division of Financial Responsibility (DOFR) to claims processing, and managed care payment rules.</p><p>An advanced knowledge of contractual pricing mechanisms for inpatient, outpatient, Long Term Care (LTC) and ancillary services.</p><p>Knowledge of relevant regulatory requirements (DMHC, DHCS, CMS).</p><p>Exceptional written and verbal communication skills, including executive communication.</p><p>Strong analytical and decision-making skills for complex claim scenarios.</p><p>Ability to provide reporting requirements based on processes and/or regulatory requirements.</p><p>Proven problem-solving skills and ability to translate knowledge to the department.</p><p>Strong people skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.</p><p>Strong attention to detail and ability to manage multiple priorities and tight deadlines.</p><p>Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.</p><p>Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.</p><p>Must have a deep understanding of financial principles.</p><p>Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.</p><p>Demonstrated ability to make informed decisions.</p><p>Strong verbal, written communication and presentation skills.</p><p>Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.</p><p>Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Claims, Medicaid, Medicare, Insurance, Healthcare                                                    </p>

L.A. Care Health Plan

Senior Manager, Claims Administration

<p><b>Salary Range:&nbsp;</b>&nbsp;$171,925.00&nbsp;(Min.) -&nbsp;$232,100.00&nbsp;(Mid.) -&nbsp;$292,274.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Senior Director and Grievance Officer, Appeals and Grievances (A&amp;G), is responsible for leadership, operational execution, clinical and regulatory oversight, and enterprise governance of L.A. Care’s grievance, appeal, and State Fair Hearing functions across all product lines. This position ensures all cases are processed accurately and consistently with exceptional quality, and within required timeframes in alignment with federal and state regulations, contractual obligations, accreditation standards, and internal policies.</p><p>The Senior Director directs a comprehensive operating model that includes centralized intake and triage, general and clinical A&amp;G operations, regulatory auditing and reporting, quality assurance, internal controls, and enterprise-level grievance governance. The Senior Director oversees staff and ensures the organization maintains strong regulatory compliance, service quality, and documentation standards.</p><p>The Senior Director collaborates extensively with cross-functional key stakeholders to address systemic issues, strengthen preventive controls, improve service delivery, and support enterprise audit readiness. The Senior Director embodies a commitment to operational excellence, accountability, equitable member experience, and disciplined governance.</p><p>This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Develops strategic plans, drives change and influences critical business outcomes. Oversees operations, ensuring efficiency and effectiveness. Steer top-level decision-making and implement initiatives that drive organization's forward.</p><h4>Duties</h4><p>Proactively translates regulatory, clinical, and service strategy into disciplined operational execution by setting clear expectations, establishing consistent processes, and ensuring teams have the tools, training, and data needed to perform at a high level. Serves as the connective tissue between key stakeholders, ensuring complex regulatory requirements are converted into clear workflows, strong internal controls, and reliable, audit-ready outcomes. Strengthens organizational trust and supports L.A. Care’s mission by leading with transparency, leveraging data-driven insights, and prioritizing member and provider experience within a highly regulated environment.</p><p>Provides senior leadership oversight to ensure all A&amp;G operations are compliant, audit-ready, efficient, and aligned with organizational performance expectations. Leads and is accountable for the overall strategy, direction, and day-to-day operations of A&amp;G, including intake, triage, case handling, documentation, clinical decision coordination, State Fair Hearings, and regulatory submissions. Establishes departmental goals, key performance indicators (KPIs), dashboards, reporting structures, and operating rhythms to monitor and drive performance across all A&amp;G functions. Ensures consistent application of regulatory and internal requirements.</p><p>Drives operational reliability through standardized processes, workforce management, and transparent performance reporting. Ensures operational capacity aligns with demand through forecasting, workload monitoring, and resource planning. Fosters a culture of proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.</p><p>Serves as the enterprise authority on grievance and appeal requirements and ensures all case handling meets federal and state standards. Interprets, applies, and operationalizes regulatory requirements and guidance. Oversees regulatory reporting, including universe submissions, timeliness validation, case audits, quality-of-care review documentation, and readiness assessments. Ensures accurate, complete, and compliant preparation of State Fair Hearing cases, medical records, and evidentiary documentation. Responds to regulatory inquiries and leads root-cause analysis, corrective actions, and sustainability plans for identified compliance issues. Reviews and approves A&amp;G policies, procedures, templates, letters, decision frameworks, and escalation pathways.</p><p>Oversees the clinical components of A&amp;G operations to ensure appropriate medical necessity review, accurate and high-quality clinical documentation, and consistent application of evidence-based guidelines to support high-quality member care. Partners with key stakeholders to ensure clinical decision stewardship and alignment with regulatory expectations. Ensures timely identification, escalation, and resolution of quality-of-care concerns in collaboration with key stakeholders. Ensures consistency in documentation of clinical rationale, decision accuracy, and regulatory adherence across all clinical case types.</p><p>Leads a unified quality and internal control environment spanning general operations, clinical operations, and regulatory auditing. Oversees the A&amp;G quality assurance program, ensuring ongoing monitoring for accuracy, documentation quality, and compliance. Ensures development and maintenance of standard operating procedures, desktop guides, decision trees, templates, and training materials. Directs all audit readiness activities, including internal audits, mock audits, and enterprise corrective action plans. Collaborates with internal leaders to strengthen controls and ensure sustainable compliance. Oversees training and competency validation programs for all A&amp;G personnel, ensuring readiness and capability across the department.</p><h4>Duties Continued</h4><p>Leads enterprise-wide integration of A&amp;G insights into systemic improvements and supports risk mitigation across operational domains. Partners with internal departments to resolve root-cause issues and reduce grievance drivers. Collaborates with internal departments to support regulatory filings, investigations, enterprise risk assessments, and Corrective Action Plan management. Engages with external stakeholders to resolve escalated member issues and improve service continuity. Provides leadership support and A&amp;G expertise in enterprise forums, oversight committees, and quality and service governance structures.</p><p>Ensures transparent, accurate, and actionable reporting that supports operational decision-making and continuous improvement. Oversees reporting of case volumes, trends, timeliness, quality-of-care findings, regulatory metrics, and systemic issues. Ensures high-quality analytics that inform operational refinements, service improvements, and strategic initiatives. Presents findings to key stakeholders, identifying opportunities for enterprise improvement.</p><p>Leads a large, multi-disciplinary leadership team and ensures a high-performing, accountable, and engaged workforce. Manages leadership teams responsible for general operations, clinical services, quality assurance, and regulatory auditing. Promotes a culture of operational excellence, service commitment, accountability, integrity, and continuous learning. Supports succession planning and leadership development across multiple levels within the A&amp;G organization.</p><p>Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees. Conducts strategic planning to utilize resources to meet current and future departmental and Enterprise-wide goals. Leads discussions on policy operationalization and oversees key policy perspective sharing. Manages budgets and resources effectively. Identifies and drives change initiatives. Develops and implements communication strategies. Collaborates with cross-functional teams to achieve common goals. Represents the company or organization in external interactions. Identifies and actualizes enhancements to support company vision. Develops and maintains relationships with key stakeholders.</p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 9 years of experience in health plan operations, managed care, A&amp;G, utilization management, clinical operations, or regulatory compliance.</p><p>At least 8 years of leading staff, supervisor/management experience.</p><p>Experience leading teams, projects, initiatives, or cross-functional groups.</p><p>Extensive leadership experience in Medicaid, Medicare, and Commercial managed care lines of business., with deep understanding of their operational, regulatory, and service requirements.</p><p>Experience navigating regulatory and accreditation requirements, with a strong track record of applying complex regulatory standards to grievance, appeal, and quality-of-care operations.</p><p>Experience improving operational accuracy, strengthening documentation quality, and ensuring consistent alignment with federal and state regulatory expectations.</p><p>Experience leading organizations through high-stakes regulatory audits, with a consistent record of achieving compliant outcomes and driving sustainable remediation.</p><p><strong>Preferred:</strong></p><p>Extensive experience working within delegated, plan-partner, or subcontracted network environments, with demonstrated ability to oversee performance, ensure compliance, and manage complex accountability structures.</p><p>Experience leading vendor management activities, including performance oversight, Service Level Agreement (SLA) adherence, quality monitoring, and alignment with regulatory and contractual requirements.</p><p>Experience developing analytic dashboards and visualization tools (e.g., Power BI, Tableau) to support trend analysis, performance monitoring, and decision-making.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Exceptional interpersonal and leadership capabilities, with the ability to inspire, develop, and empower teams while driving accountability, consistency, and high performance across all levels.</p><p>Expert knowledge of grievance, clinical decision-making, and managed care regulatory standards, with the ability to translate complex requirements into effective operational processes.</p><p>Advanced strategic and analytical skills to interpret trends, assess operational and regulatory risk, and design sustainable, data-driven solutions.</p><p>Deep and comprehensive understanding of regulatory requirements for all lines of business.</p><p>Ability to lead effectively in complex, high-volume, and highly regulated environments with competing priorities, rapid demand shifts, and significant compliance requirements.</p><p>Exceptional influence and stakeholder engagement skills to translate complex concepts into clear, actionable guidance for diverse audiences.</p><p>Strong leadership presence and leadership acumen, with demonstrated success managing, mentoring, and developing multi-level teams in operational and regulatory disciplines.</p><p>Ability to design, implement, and sustain standardized processes, governance frameworks, and internal control structures that enhance accuracy, compliance, and operational reliability.</p><p>Strong planning, prioritization, and organizational skills with attention to detail and a proven ability to manage multiple concurrent priorities with urgency, accuracy, and sound judgment.</p><p>Proficient with Microsoft Office, reporting platforms, and case management systems, with the ability to leverage technology to improve operational visibility and performance.</p><p>Ability to lead comprehensive regulatory audit readiness and response efforts, including universe submissions, documentation validation, corrective action development, and sustainability planning.</p><p>Ability to lead operational transformation initiatives while maintaining a strong culture of regulatory compliance, accountability, and service excellence.</p><p>Ability to lead technology-enabled operational improvements, including system implementation, enhancement prioritization, and maintenance oversight to drive efficiency and reliability.</p><p>Ability to think long-term and develop strategies that align with the overall goals of the organization.</p><p>Ability to make sound and timely decisions.</p><p>Ability to adapt to changing situations and adjust strategies accordingly.</p><p>Ability to adapt to a fast-paced and evolving environment and to lead others through change.</p><p>Exceptional interpersonal, verbal, and written communication skills, including executive communication with ability to produce audit-ready documentation.</p><p>Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Registered Nurse (RN) - Active, current and unrestricted California License<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.</p><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Nursing, Registered Nurse, Medicaid, Medicare, Fundraising, Healthcare, Nonprofit                                                    </p>

Senior Director and Grievance Officer, Appeals and Grievances

<p><b>Salary Range:&nbsp;</b>&nbsp;$135,136.00&nbsp;(Min.) -&nbsp;$175,676.00&nbsp;(Mid.) -&nbsp;$216,218.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Director, Claims Administration, governs enterprise outcomes and risk controls, introducing a preventative orientation and regulatory accountability.&nbsp; This position is responsible for leading the end-to-end claims ecosystem, including claims adjudication, claims adjustments (escalations, disputes, general adjustments, and litigation-related requests), and strong focus on preventative controls through the Service Validation Unit (SVU). This role ensures timely, accurate, and complaint processing across all lines of business while strengthening upstream quality, embedding consistent control points, and reducing operational rework.&nbsp;</p><p>The Director has ownership of claims regulatory compliance and audit readiness.&nbsp; This position oversees daily production, inventory management, adjustment workflows, regulatory turnaround requirements, benefit and authorization interpretation, provide payment accuracy, and operational readiness for benefit, system, or regulatory changes. The role serves as an operational expert on managed care payment rules provider contracts, regulatory requirements, and claims operational dependencies.</p><p>The Director partners closely with cross functional teams to ensure end-to-end accuracy and operational integrity. This position fosters a culture of accountability, transparency, operational consistency, and continuous improvement.</p><p>This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; Develops strategic plans, drives change and influences critical business outcomes.</p><h4>Duties</h4><h4>Translates organizational expectations into disciplined operational execution by creating predictable workflows, establishing strong preventative control environments, and ensuring that claims processing is accurate, timely, and complaint. &nbsp;Strengthens upstream quality, improves consistency through standardized processes, ensures rigorous adherence to regulatory and contractual requirements, and supports an operational model that aims to remove rework, prevents defects, and supports high-performing administrative operations.</h4><h4>Through ownership of regulatory compliance and audit readiness perspective, provides strategic and operational leadership for all aspects of claims adjudication across all lines of business.</h4><h4>Monitors daily, weekly, and monthly production performance to ensure accuracy, timeliness, and regulatory compliance.&nbsp; Oversees examiner productivity models, workload balancing, Quality Assurance performance, and inventory trending to ensure strong operational predictability.&nbsp; Ensures benefit, authorization, eligibility, and provider data issues are resolved quickly and consistently, with emphasis on preventing repeat defects.&nbsp; Supports enterprise initiatives requiring claims operational expertise.&nbsp; </h4><h4>Leads all adjustment workflows, including escalations, provider disputes, general adjustments, and litigation-related claims review.&nbsp; Ensures all regulatory turnaround times (TATs) and provider/member notice requirements are consistently met, documented, and monitored.&nbsp; Services and the operational escalation point for high-visibility or high-complexity claim issues, including those involving regulators, legal, provider groups, or executive leadership. Develops standardized adjustment pathways that improve cycle time and reduce manual rework.<br><br></h4><h4>Establishes and leads the Service Validation Unit (SVU) to function in a strategic, proactive and preventative manner by independently validate that billed services were authorized, medically supported, accurately represented, and provided/received prior to payment.&nbsp; Ensures SVU findings translate into upstream, corrections, system or process improvements, and improved preventive controls.</h4><h4>Develops and leads initiatives to improve first-pass accuracy, reduce rework, shorten cycle time, and advance operational maturity.&nbsp; Participates in and partners through quality review processes to ensure adherence to regulatory and contractual processing standards.&nbsp; Oversees root-cause analysis of defects or variances, ensuring permanent corrective actions and improved upstream controls.&nbsp; Partners with stakeholder departments on regulatory reviews, corrective actions, and audit responses. Ensures the accuracy and timeliness of responses to regulators and external partners.</h4><h4>Duties Continued</h4><h4>Directs production, quality, and operational performance reporting, identifying trends, risks, and improvement opportunities.&nbsp; Ensures reporting supports proactive decision-making and enables early identification of potential inventory or compliance risks. Partners to establish/refine dashboards for visibility into accuracy, timeliness, adjustments, disputes, and SVU outcomes.</h4><p>Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees. Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Develops, and manages budgets, utilizing resources effectively.&nbsp;</p><p>Conducts strategic planning to utilize resources in order to meet current and future departmental and Enterprise-wide goals.&nbsp; Identifies and actualizes enhancements to support company vision.&nbsp;</p><p>Develops and maintains relationships with key stakeholders.&nbsp; Leads discussions on policy operationalization and oversees key policy perspective sharing.</p><h4>Ensures strong technical capability, a culture of accountability, and consistent performance.&nbsp; Fosters a culture of proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.</h4><h4>Performs additional duties as assigned.</h4><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:<br></strong></p><p>At least 7 years of healthcare claims (Medicare, Medicaid, and Commercial) experience.</p><p>At least 5 years of experience leading, supervising and/or managing staff.</p><p>Experience in Medicaid, Medicare, and Commercial managed care lines of business.</p><p>Demonstrated experience leading claims adjudication, adjustments, disputes, escalations, and related functions.</p><p>Extensive experience interpreting provider contracts, payment methodologies, and managed care benefit structures</p><p>Experience handling complex claim review, root-cause evaluation, adhering to regulatory timeliness requirements, and ensuring accuracy.</p><p>Significant experience administering quality review programs and implementing sustainable operational improvements.</p><p>Experience supporting litigation, state or federal inquiries, and regulatory audits.</p><p>Demonstrated experience with high complexity claims review and RCA.</p><p><strong>Preferred:</strong></p><p>Experience leading a service validation or similar preventive quality/control unit.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong understanding of managed care contracts, benefit structures, payment methodologies, and authorization requirements.</p><p>Strong interpersonal leadership skills and an ability to motivate and develop talent while driving accountability.</p><p>Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing.</p><p>Extensive knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD)-10, DRG/ Ambulatory Payment Classification (APC), and pricing methodologies.<br>Deep study and understanding of managed care contracts and payment methodologies and provide contract interpretation.</p><p>Strong project leadership and management skills required; ability to manage multiple priorities, complex workflows, and high-volume environments.</p><p>Proficiency with Microsoft Office and data/reporting tools.</p><p>Exceptional presentation skills, written and verbal communication skills, including executive communication skills with the ability to produce audit-ready documentation.<br>Must be highly collaborative and maintain a consultative style with ability to establish credibility quickly with all levels of management across multiple functional areas.</p><p>Must be able to present findings to various levels of management, across all organizations.</p><p>Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization.</p><p>Demonstrated ability to make sound and timely decisions.</p><p>Demonstrated ability to adapt to changing situations and adjust strategies accordingly.</p><p>Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change.</p><p>Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment.</p><p>Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Certified Professional Coder (CPC)<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Medical Coding, Claims, Medicare, Medicaid, Healthcare, Insurance                                                    </p>

Director, Claims Administration

<p><b>Salary Range:&nbsp;</b>&nbsp;$135,136.00&nbsp;(Min.) -&nbsp;$175,676.00&nbsp;(Mid.) -&nbsp;$216,218.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Director, Center of Excellence &amp; Quality Assurance is responsible for leading the quality, compliance, training, and continuous improvement functions that ensure L.A. Care’s Core Administrative Operations ecosystem operates with accuracy, integrity, and regulatory readiness. This role builds a disciplined quality framework that strengthens upstream and downstream controls, enhances first-pass accuracy, reduces defects, and ensures consistent, predictable outcomes across Claims Administration, Configuration, Payment Integrity, and related operational areas.</p><p>The Director oversees enterprise claims quality auditing, claims compliance oversight, issue detection and validation, corrective action planning, root-cause analysis, and enterprise reporting on quality performance. This role oversees enterprise quality for both operational claims processing and system configuration, ensuring the accuracy of benefit builds, provider reimbursement logic, system edits, pricing methodologies, and operational rules prior to deployment and ensures the organization meets federal, state, and contractual requirements by maintaining effective monitoring, quality review programs, compliance validation, and documentation standards. The Director also leads training and policy interpretation for claims-related operations, ensuring teams have the knowledge, tools, and guidance needed to maintain accuracy and adhere to changing regulatory requirements.</p><p>The Director creates a disciplined quality framework that strengthens upstream and downstream controls, enhances first-pass accuracy, reduces defects introduced through system changes, and ensures consistent execution across Core Administrative Operations service lines. The Director serves as the primary partner to operational leaders on quality and compliance matters, providing subject matter expertise on regulatory interpretation, operational risk, quality trends, and systemic improvements. This position builds a high-performing team and fosters a culture of quality, operational rigor, accountability, and continuous improvement.</p><p>This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; Develops strategic plans, drives change and influences critical business outcomes.</p><h4>Duties</h4><p>Strengthens L.A. Care’s operational quality by creating a structured, disciplined approach to auditing, compliance, and process validation.&nbsp; Ensures quality is proactively managed, system and process changes are controlled, and risks are quickly identified and remediated. Through cross-functional collaboration, transparent reporting, and strong execution, that improves operational maturity, enhances accuracy, reduces rework, and supports sustainable performance across all core administrative operations.</p><p>Leads the continuous improvement and execution of the Core Administrative Operations quality audit program, including audit planning, sampling methodologies, examiner scorecards, and real-time quality monitoring, managing both examiner-level QA and configuration build validation.&nbsp; Ensures quality review processes measure end-to-end claims accuracy, including benefit interpretation, provider contract application, coding, pricing, and system logic.&nbsp; Oversees testing and validation of configuration changes, including benefit builds, reimbursement tables, pricing logic, clinical/non-clinical edits, and system enhancements.</p><p>Ensures robust pre-production testing (unit, peer, end-to-end, and regression testing) for all configuration changes.&nbsp; Implements quality gates and validation checkpoints to prevent configuration-related defects from reaching production.&nbsp; Builds and maintains quality dashboards and performance reports to provide transparency to leadership and operational teams.&nbsp; Oversees validation of operational improvements, new processes, and system changes to ensure sustained accuracy and alignment with expected outcomes.</p><p>Ensures compliance with all regulatory requirements, including the Department of Managed Health Care (DMHC), the California Department of Health Care Services (DHCS), the Centers for Medicare and Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and contractual obligations related to claims accuracy, turnaround times, interest payments, notices, and documentation.</p><p>Leads or supports internal and external audits, including preparation, documentation, sample reviews, responses, and corrective action plans.&nbsp; Monitors regulatory changes, interprets requirements, and ensures claims operations and related departments adopt compliant practices.&nbsp; Directs compliance monitoring of claims processing, Payment Integrity interventions, configuration changes, and related administrative controls.</p><p>Directs root-cause analysis of quality findings to identify systemic drivers of defects, inaccuracies, or compliance risks.&nbsp; Develops corrective action plans (CAPs) with clear ownership, timelines, and measurable outcomes; monitors implementation to ensure sustainable resolution.&nbsp; Provides findings to operational leaders and supports development of upstream fixes that reduce rework and strengthen control points.&nbsp; Tracks and trends error patterns to proactively identify emerging risks and improvement opportunities.</p><h4>Duties Continued</h4><p>Establishes and maintains standard operating procedures, quality checkpoints, and control frameworks across related functions, ensuring consistency of processes, documentation, and quality standards.&nbsp; Ensures all system/benefit changes have proper impact assessments, approval workflows, and documented validations prior to production deployment.&nbsp; Strengthens alignment and consistency across teams by deploying standardized guidelines, documentation practices, and cross-functional workflows.</p><p>Ensures operational readiness for regulatory updates, benefit changes, system enhancements, and organizational initiatives by validating impacts on quality.&nbsp; Partners with Configuration and Claims Administration to ensure system logic and operational workflows support accurate processing.</p><p>Oversees development and delivery of training programs related to claims accuracy, policy interpretation, regulatory requirements, documentation standards, and quality expectations.&nbsp; Ensures training programs are aligned with audit findings, regulatory changes, and systemic improvement needs.&nbsp; Maintains updated knowledge repositories, training materials, and reference documentation to support consistent operational execution.&nbsp; Provides coaching to leaders and teams on quality standards, audit results, and improvement expectations.</p><p>Serves as a strategic advisor to operational, technical, and management teams on quality, compliance, and process improvement initiatives.&nbsp; Collaborates with cross-functional teams to address quality issues and implement sustainable solutions.&nbsp; Provides input on operational readiness for system changes, regulatory updates, and enterprise improvement work.&nbsp; Represents the quality and compliance perspective in governance forums, operational reviews, and cross-functional committees.</p><p>Develops and maintains dashboards, KPIs, and scorecards to monitor quality performance, compliance adherence, and systemic risks.&nbsp; Ensures leadership receives clear, actionable insights on trends, risks, and opportunities for improvement.&nbsp; Monitors the effectiveness of quality interventions and updates strategies based on performance data.</p><p>Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees. Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Develops, and manages budgets, utilizing resources effectively.&nbsp;</p><p>Conducts strategic planning to utilize resources in order to meet current and future departmental and Enterprise-wide goals.&nbsp; Identifies and actualizes enhancements to support company vision.&nbsp;</p><p>Develops and maintains relationships with key stakeholders.&nbsp; Leads discussions on policy operationalization and oversees key policy perspective sharing.</p><p>Leads, trains, develops, and manages a team of quality auditors, compliance analysts, training specialists, and process improvement staff.&nbsp; Develops specialized configuration QA capabilities (e.g., test scripts, regression suites, system scenario modeling).&nbsp; Oversees hiring, training, performance evaluations, coaching, and succession planning.&nbsp; Fosters a culture of integrity, accountability, operational rigor, and continuous improvement.</p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 7 years of deep experience in claims quality, claims compliance, auditing, or related managed care administrative functions.</p><p>At least 5 years of experience leading, supervising and/or managing staff.</p><p>Experience in Medicaid, Medicare, and Commercial managed care lines of business.</p><p>Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing.</p><p>Demonstrated experience leading enterprise audit programs or quality assurance functions.</p><p>Experience interpreting regulatory requirements and applying them to operational workflows.</p><p>Experience overseeing corrective action implementation, issue remediation, or regulatory readiness activities.</p><p>Extensive experience supporting or preparing for regulatory audits ((Department of Managed Health Care (DMHC), California Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS)), including corrective action planning.</p><p><strong>Preferred:</strong></p><p>Experience partnering with technical and configuration teams to validate system changes.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong interpersonal leadership skills and an ability to motivate and develop talent while driving accountability.</p><p>Extensive knowledge of claims adjudication, benefit structures, provider contracting, DoFR, pricing rules, and coding standards (Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS)/ International Classification of Diseases (ICD)/ Diagnosis Related Group (DRG)).</p><p>Strong understanding of regulatory requirements and compliance frameworks.</p><p>Advanced analytical, problem-solving, and root-cause analysis skills.</p><p>Strong project leadership and organizational skills; able to manage multiple priorities simultaneously.</p><p>Exceptional interpersonal, verbal, and written communication skills, including executive communication with ability to produce audit-ready documentation.</p><p>Ability to work collaboratively across diverse teams and influence without direct authority.</p><p>Proficiency with Microsoft Office and data reporting tools.</p><p>Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization.</p><p>Demonstrated ability to make sound and timely decisions.</p><p>Demonstrated ability to adapt to changing situations and adjust strategies accordingly</p><p>Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change.</p><p>Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment</p><p>Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Claims, Medicaid, Medicare, Insurance, Healthcare                                                    </p>

Director, Center of Excellence and Quality Assurance

<p><b>Salary Range:&nbsp;</b>&nbsp;$55,245.00&nbsp;(Min.) -&nbsp;$69,045.00&nbsp;(Mid.) -&nbsp;$82,867.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Lead Service Liaison position is responsible for supporting daily management functions of the outreach team, helping ensure productivity, quality, and performance targets are met.</p><p>This position serves as the subject matter expert for the execution of member and provider outreach efforts for all lines of business. This position leads and works closely with assigned team daily. This position will mentor, coach, and may provide feedback to management on performance of staff. Ensure team effectiveness and project completion.</p><h4>Duties</h4><p>Monitors and facilitates timely contact of members regarding all outreach and retention programs for all lines of business. Provides recommendations for process improvements. Monitors real-time activity and campaign management, as needed. Ensures system of record is functional to provide complete, accurate information. (50%)</p><p>Assists management in ensuring staff provides accurate, timely and quality service to our members and providers, ensuring adherence to all departmental policies, procedures, and standards. Assists with special projects and campaigns that can provide feedback for membership satisfaction. Assists with campaign management functions for outreach efforts across all lines of business. (20%)</p><p>Assists management in providing accurate and timely reports to senior leadership. Performs Quality Assurance functions for vendor outbound campaigns. Interfaces and collaborates with management and stakeholders within and outside of the organization to address and resolve questions, elevate areas of member dissatisfaction, and barriers to care. Assists with identifying and implementing related process and system improvements. (20%)</p><h4>Leads the work of assigned staff; regularly assigns and checks the work of others, providing guidance, training, and feedback on performance to department management. Assist management in the oversight of the daily office workflow, recommends enhancements to process and procedures.</h4><h4>Guide the assigned staff in ensuring that the team's work is completed effectively. May assist in the assigning tasks and communicating project goals. Participates in team problem-solving, decision-making, and conflict resolution.</h4><h4>Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval.</h4><h4>Performs other duties as assigned. (10%)</h4><h4>Duties Continued</h4><h4>Education Required</h4>High School Diploma/or High School Equivalency Certificate<h4>Education Preferred</h4>Associate's Degree<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 2 years of customer service experience in a contact center environment, preferably in a managed care plan setting.</p><p>At least 3 months of experience leading a process, program, and/or staff.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong coaching and motivational skills.</p><p>Proficiency with Customer Relationship Management (CRM) systems and dialing platforms.</p><p>Ability to analyze data and make performance-driven recommendations.</p><p>Proficiency in Microsoft Office suite.</p><p>Ability to communication, conflict resolution, and motivational skills.</p><p>Ability to collaborate closely with a team in a collaborative and interactive environment.</p><p>Skilled in fostering teamwork and collaboration.</p><p>Ability to adjust to changing circumstances within the team.</p><p>Good verbal and written communication skills.</p><p><strong>Preferred:</strong></p><p>Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese&nbsp;&nbsp;</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Relationship Manager, Customer Service                                                    </p>

Lead Service Liaison

<p><b>Salary Range:&nbsp;</b>&nbsp;$88,854.00&nbsp;(Min.) -&nbsp;$115,509.00&nbsp;(Mid.) -&nbsp;$142,166.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Business Analyst III facilitates business process improvement via the methodical investigation, analysis, review and documentation of functional business specifications. This position manages the requirements development process through the elicitation, analysis, specification and verification of multiple levels of requirements from an end-to-end perspective and supports the ongoing management of the requirements. This position develops report and analysis for the department. It is responsible in communicating and coordinating with IT on a day-to-day department related efforts. The Business Analyst III manages and coordinates the implementation and/or integration of products or new features for clients including client training and provides subject matter expertise (SME) and support of the department's inbound and outbound functions. This position acts as mentor to Business Analysts I/ II.</p><h4>Duties</h4><p>Develop functional and user acceptance test plans and scenarios. Coordinate functional and user acceptance testing by executing the testing strategy, scheduling resources and tracking test performance. Perform data analysis to support evaluation of system defects or to develop requirements for new functionality; assist in various system trouble shooting and balancing and correction efforts including analysis, verification and validation of issues and fixes. Coordinate activities including on-time delivery, testing and production moves.</p><p>Collaborate with I.T. on all department &nbsp;related efforts, including submission of Service Requests and writing BRD's. Coordinate related data requests from internal departments, and/or assist I.T. with definition of criteria. Delegate data and reporting requests to business analysts. Facilitate collaborative system and data design sessions with the user community, technical architecture resources and development resources. Preparation of status updates to enterprise for distribution and communication.</p><p>Work as a technical support and liaison to designated I.T. personnel to provide testing, support and feedback on enhancement requests and regular updates/releases; adhere to release schedules. Provide analytical support for critical corporate initiatives including business function support for system migrations and consolidations, significant business area process improvement projects and complex product installations.</p><p>Demonstrate a high level of subject matter expertise in functional area to bridge business requirements and I.T. solutions; provide technical direction and ensure compliance with best practice solutions. Practice knowledge transfer and foster change management as the organization changes and new skills are required, focusing on team/individual development to be a valued contributor.</p><p>Participate and contribute on the development/ creation of data models and interface design specifications. Support internal/ external stakeholder's roadmap and audits as needed.</p><p><br>Oversee the business process support across multiple client engagements. Communication with internal/ external stakeholders for department's submission requirements. Review submission of data against established benchmarks and coordinate correction and improvement efforts. Monitor timely and accurate outbound data submission to state and federal recipients.</p><h4>Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.</h4><h4>Perform other duties as assigned.</h4><h4>Duties Continued</h4><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4><h4>Experience</h4><p><b>Required:</b></p><p>At least 5 years of successful experience in a quantitative role as a Business Analyst, Data Analyst, Programming Analyst, Claims processing, encounter processing.</p><h4>Skills</h4><p><strong>Required:</strong><br>Competent to work at the highest technical level of most phases of systems analysis.</p><p>Excellent verbal and written communication skills.</p><p>Coaching, Mentoring and Teaching skills.</p><p>Teamwork-focused/collaborative work style.</p><p>Demonstrated ability to work successfully on large projects.</p><p>Problem solving skills evidenced by demonstrated results in past positions.</p><p>Ability to work under tight deadlines and handle multiple/detail-oriented tasks.</p><p>Ability to influence at all levels of the organization.</p><p>Proficient in Microsoft Office and Vizio.</p><p><strong>Preferred:</strong><br>Ability to work on other programs such as SharePoint and/ or OneNote</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Department Specifics:</b></p><p><b>Customer Solution Center Appeals and Grievances:</b></p><p>This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.</p><p>This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned</p><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Business Analyst, Claims, Finance, Insurance                                                    </p>

Business Analyst III

<p><b>Salary Range:&nbsp;</b>&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Senior Manager, Payment Integrity (PI) Operations, manages and leads critical components of L.A. Care’s enterprise Payment Integrity program, overseeing the design, execution, and continuous refinement of pre-payment and post-payment accuracy activities. This position integrates operational management with analytic, regulatory, and contract-driven development to prevent inappropriate payments, strengthen upstream controls, and ensure accurate financial outcomes across all lines of business.</p><p>The Senior Manager manages multi-functional teams responsible for prospective edit development, clinical and non-clinical pre-payment reviews, retrospective audits, overpayment/underpayment identification, recovery operations, and pipeline management. This position ensures PI programs are executed consistently, documented clearly, and aligned with regulatory, contractual, and financial expectations.</p><p>The Senior Manager works closely with cross-functional stakeholders to translate insights into actionable system changes and preventive modifications. The Senior Manager serves as the operational driver for Payment Integrity interventions, ensuring programs scale effectively, are audit-ready, and deliver measurable reductions in inaccurate or wasteful spend.</p><p>Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.&nbsp; Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.</p><p>Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.</p><h4>Duties</h4><p>Leads daily operations of pre-pay and post-pay PI activities, ensuring accuracy, timeliness, and effective case management. Oversees prospective review programs including clinical editing, code auditing, algorithm-driven controls, and provider contract/benefit interpretation. Ensures post-pay functions, including data mining, recovery validation, provider outreach, and reconciliation, are accurate, transparent, and compliant. Establishes standardized workflows, documentation, and quality review expectations across all PI teams. Ensures Payment Integrity operates as a disciplined, analytically driven, and preventive control function.</p><p>Strengthens the reliability of claims processing, increases automation and cost avoidance, manages complex PI workflows, and translates regulatory and contract-driven requirements into systematic, sustainable accuracy improvements.</p><p>Oversees development, refinement, and implementation of new edits, rules, and clinical/non-clinical logic that reduce future payment errors. Translates regulatory updates, provider contract terms, benefit changes, and emerging industry standards into edit or algorithm recommendations. Manages the PI pipeline of prospective initiatives, ensuring strong prioritization, impact modeling, and timely deployment. Partners with key stakeholders to implement upstream corrections and reduce recurring defects. Ensures prospective controls improve auto-adjudication, accuracy, and reduction of rework.</p><p>Oversees identification and validation of overpayments and underpayments from solicited/unsolicited sources, analytics, and vendor partners. Ensures recoveries follow compliant workflows, including provider notification, appeal support, repayment management, and financial reconciliation. Ensures post-pay insights translate into upstream corrective actions, edit changes, or preventive improvements. Oversees development of operational processes that strengthen coordination between internal recovery teams and external vendors.</p><p>Directs analytic and data mining efforts to detect billing anomalies, emerging risk patterns, and high-impact cost avoidance opportunities. Partners with enterprise analytics to refine predictive modeling, trending dashboards, and reporting frameworks. Ensures analytical findings convert into operational interventions, policy updates, or system changes. Identifies high-risk providers, services, or claims behaviors requiring new controls or deeper review.</p><h4>Duties Continued</h4><p>Ensures PI programs align with federal, state, and contractual requirements for all lines of business. Interprets regulatory updates and directs teams to integrate changes into rules, workflows, and edit development. Ensures that benefit structures, contract terms, and pricing methodologies are correctly reflected in both pre- and post-pay activities. Partners with Compliance and SIU on cases requiring heightened review or escalated investigation.</p><p>Oversees operational execution of vendor-driven PI programs, ensuring strong Service level agreement (SLA) performance, validated results, and accurate financial reporting. Supports vendor onboarding, implementation, testing, and algorithm or rule customizations. Ensures internal teams coordinate effectively with external partners across pre-pay and post-pay programs.</p><p>Partners with cross-functional key stakeholders to resolve system issues and strengthen upstream accuracy. Serves as an advisor to internal partners on PI trends, risk areas, provider behavior insights, and recommended control changes. Ensures PI findings are shared proactively and used to influence broader operational and configuration improvements.</p><p>Manages staff and the day-to-day activities in the department. Participates in the department budgeting process.&nbsp; Responsible for scheduling, training, performance, corrective actions, mentoring, developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and problem-solving skills across the team.</p><p>Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/ or executive management to define, prioritize, and develop projects and programs.</p><p>Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.</p><p>Responsible for overseeing and managing the budgets of their respective departments.</p><p>Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval.</p><p>Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities.</p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:&nbsp; </strong></p><p>At least 6 years of Payment Integrity, Program Integrity, medical cost containment, Fraud Waste and Abuse (FWA), data mining, claim accuracy, or related experience.</p><p>At least 5 years of experience in leading staff, Supervising and/or managing staff.</p><p>Experience leading teams, projects, initiatives, and cross-functional groups.</p><p>Experience in Medicaid, Medicare, and Commercial managed care lines of business.</p><p>Experience in pre-pay and/or post-pay review, edit development, recovery operations, or claim logic development.</p><p>Experience interpreting provider contracts, payment methodologies, and managed care benefit structures.</p><p>Experience handling complex claim review, root-cause evaluation, and adhering to regulatory TAT requirements</p><p>Experience working with COB and Third-Party Liability (TPL) claims in a managed care setting.</p><p>Experience with vendor-managed PI programs.</p><p><strong>Preferred:</strong></p><p>Experience applying predictive analytics or algorithm-based PI solutions.</p><p>Experience with SQL, BI tools, or data mining platforms.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong understanding of adjudication, coding, and the application of Division of Financial Responsibility (DOFR) to claims processing.</p><p>Extensive knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD)-10, DRG/ Ambulatory Payment Classification (APC), and pricing methodologies.</p><p>Understanding of benefit interpretation, contract terms, and payment rules.</p><p>Strong analytical, investigative, financial, and operational skills.</p><p>Exceptional written and verbal communication skills, including executive communication and the ability to translate technical findings into actionable recommendations.</p><p>Advanced project leadership, workflow management, and prioritization skills.</p><p>Ability to collaborate with internal and external stakeholders at all levels.</p><p>Proven problem-solving skills and ability to translate knowledge to the department.</p><p>Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.</p><p>Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.</p><p>Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.</p><p>Must have a deep understanding of financial principles.</p><p>Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.</p><p>Demonstrated ability to make informed decisions.</p><p>Strong verbal, written communication and presentation skills.</p><p>Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.</p><p>Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.</p><p><strong>Preferred:</strong></p><p>Knowledge of SIU/FWA methodologies and risk indicators.</p><p>Experience with SQL, BI tools, or data mining platforms.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4>Certified Professional Coder (CPC) designation by the American Academy of Professional Coders<h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Medical Coding, Claims, Medicare, Medicaid, Healthcare, Insurance                                                    </p>

Senior Manager, Payment Integrity Operations

<p><b>Salary Range:&nbsp;</b>&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Senior Manager, Electronic Data Interchange (EDI) &amp; Data Operations is responsible for leading and optimizing the day-to-day operational, analytical, and technical functions that support electronic data exchange, authorization data ingestion, accumulator management, and Explanation of Benefits (EOB) processing for L.A. Care. This includes operational oversight of all Health Insurance Portability and Accountability Act (HIPAA) standard and proprietary EDI transactions, delegated and internal authorization data loads, accumulator workflows, and the operational components of EOB generation and remediation.</p><p>The Senior Manager oversees a team who manage file intake, data validation, routing, reconciliation, testing, and issue resolution across the enterprise. This position ensures that all electronic and paper-to-electronic data supporting claims and administrative operations is accurate, timely, and compliant with regulatory, contractual, and quality expectations.</p><p>This position plays a critical leadership role in enhancing upstream controls, reducing rework, improving automation, supporting system changes, and driving continuous improvement in data operations.</p><p>Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.&nbsp; Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.</p><p>Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.</p><h4>Duties</h4><p>Strengthens the reliability, accuracy, and efficiency of all electronic data processes that support claims operations, ensuring data flows through systems as intended, issues are rapidly identified and remediated, and upstream controls are continuously enhanced. Helps drive predictable outcomes, improve payment accuracy, and maintain regulatory readiness across the data ecosystem.</p><p>Manages end-to-end operational oversight of all inbound and outbound HIPAA-standard and proprietary EDI transactions (837, 835, 270/271, 276/277, 834, 278). Ensures timely, accurate, and compliant processing of electronic claims, encounters, eligibility updates, and related administrative data.</p><p>Oversees transaction monitoring, exceptions, error queues, and data rejects; ensures prompt triage and resolution. Provides oversight of requirements documentation, including business and functional requirements (BRDs/FRDs), workflow mapping, and data specifications that support operational effectiveness.</p><p>Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities.&nbsp;</p><p>Leads oversight of delegated Electronic Load of Delegated Authorizations (ELDA) and internal clinical authorization data loads into QNXT. Ensures authorization data is timely, complete, reconciled, and supportive of accurate claims adjudication.</p><p>Monitors authorization load success rates and partners with upstream teams to resolve recurring issues. Guides enhancements that reduce manual lookup burden for claims and increase automation.</p><p>Manages operational components of the Member Out-of-Pocket (MOOP) accumulator workflow, including reconciliation, error correction, escalation management, and member remediation.</p><p>Ensures accumulator data is accurate across intake systems, accumulator databases, QNXT, and output files.</p><p>Provides reporting and trending on accumulator performance, error patterns, and upstream causes.</p><p>Shares responsibility with the Director, EDI for operational oversight of EOB generation, validation, and data flow.</p><p>Ensures EOB output files reflect accurate benefit application, share of cost, accumulation, claim decisions, and meets regulatory requirements. Troubleshoots and resolves EOB-related issues, including cost-share miscalculations, missing data, formatting discrepancies, and system defects. Supports testing of EOB templates, logic updates, and system enhancements that impact EOB accuracy and delivery.</p><p>Leads complex root cause analyses for issues impacting claims data, authorizations, accumulators, or EOBs.</p><h4>Duties Continued</h4><p>Coordinates remediation efforts with cross-functional departments. Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/ or executive management to define, prioritize, and develop projects and programs.</p><p>Ensures corrective actions are documented, validated, and monitored to prevent recurrence. Identifies systemic issues and recommends upstream solutions to strengthen operational controls and improve accuracy.</p><p>Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions. Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Leads process and workflow redesign efforts to increase automation, reduce manual work, and improve overall data quality.</p><p>Oversees User Acceptance Testing (UAT) planning, test case creation, execution, and validation for system changes affecting EDI, authorization data, accumulators, and EOBs.</p><p>Ensures strong quality gates are consistently applied before production releases.</p><p>Works closely with the Director, EDI to prioritize enhancements and support operational readiness for system changes.</p><p>Serves as an operational liaison to cross-functional departments and delegated entities.</p><p>Communicates system availability, planned changes, incident statuses, and file processing updates clearly and consistently.</p><p>Supports internal and external partners with non-standard data requests, testing analysis, and troubleshooting.</p><p>Manages staff and the day-to-day activities in the department. Participates in the department budgeting process. Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team. Responsible for overseeing and managing the budgets of their respective departments.</p><p>Maintains a culture of rigor, transparency, analytical curiosity, proactive issue identification, cross-functional communication, accountability, and continuous operational improvement.</p><p>Perform other duties as assigned.&nbsp;</p><h4>Education Required</h4>Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.<h4>Education Preferred</h4>Master's Degree in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 6 years of experience working with healthcare data, EDI transactions, claims data operations, or managed-care administrative systems.</p><p>At least 5years of experience in leading, supervising and/or managing staff.</p><p>Experience with system integrations, data migrations, or large-scale technical implementations.</p><p>Demonstrated experience leading complex issue resolution and root cause analysis efforts.</p><p>Experience leading teams, projects, initiatives, or cross-functional groups</p><p><strong>Preferred:</strong></p><p>Experience developing test cases, leading UAT, or supporting system configuration changes.</p><p>Experience with commercial health plan operations or delegated partner management.</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Strong knowledge of HIPAA-standard EDI transactions and healthcare data structures.</p><p>Knowledge of MOOP accumulators, authorization workflows, and EOB data flows.</p><p>Familiarity with claims adjudication rules, cost-share logic, and benefit application.</p><p>Proficiency in SQL, Access, Excel, and related reporting or analysis tools.</p><p>Ability to interpret and produce BRDs, FRDs, process flows, and technical documentation.</p><p>Strong analytical, problem-solving, and system-thinking skills.</p><p>Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.</p><p>Excellent attention to detail and ability to manage multiple priorities and tight deadlines.</p><p>Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.</p><p>Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.</p><p>Ability to develop and manage budgets, forecast future financial outcomes, and make informed decisions about resource allocation.</p><p>Demonstrated ability to make informed decisions.</p><p>Excellent verbal, written communication, and presentation skills.</p><p>Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.</p><p>Strong ability to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.</p><p><strong>Preferred:</strong></p><p>Working knowledge of relational databases, system interfaces, or data transformation logic.</p><p>Experience with delegated entity data submissions or clearinghouse integrations.</p><h4>Licenses/Certifications Required</h4><h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Claims, Insurance                                                    </p>

Senior Manager, Electronic Data Interchange and Claims Data Operations

<p><b>Salary Range:&nbsp;</b>&nbsp;$117,509.00&nbsp;(Min.) -&nbsp;$152,762.00&nbsp;(Mid.) -&nbsp;$188,015.00&nbsp;(Max.)</p><p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br><br>Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br></p><h4>Job Summary</h4><p>The Senior Manager, Clinical and Regulatory Operations, is responsible for leading clinical case operations, regulatory interpretation, and clinical decision stewardship across all grievance, appeal, and State Fair Hearing cases. This position ensures that clinical and non-clinical case handling meets medical necessity standards, regulatory requirements, internal policy expectations, and quality-of-care obligations across all product lines, including Medi-Cal, Medicare, Marketplace, and delegated entities.</p><p>The Senior Manager oversees clinical operations teams responsible for medical necessity reviews, clinical grievances and appeals, Quality of Care (QOC) referrals, clinician coordination, clinical documentation quality, and regulatory interpretation. The role ensures strong collaboration with Utilization Management, the UM Medical Director, physician reviewers, Compliance, Member Services, Provider Network Management, claims teams, and the Center of Quality &amp; Excellence to support compliant, timely, and high-quality case handling.</p><p>The Senior Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.&nbsp; Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.&nbsp; Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.</p><p>Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.</p><h4>Duties</h4><p>Oversees end-to-end clinical case handling, including clinical grievances, clinical appeals, medical necessity review coordination, and clinical case triage and ensures consistent application of evidence-based guidelines, clinical criteria, and regulatory standards in all clinical decisions. Partners with the clinical leadership to ensure clinical decision accuracy and appropriateness. Translates clinical guidelines, regulatory requirements, and service standards into operational workflows that ensure accurate, timely, and clinically sound case handling. Ensures clinical documentation is accurate, complete, defensible, and compliant with regulatory expectations.</p><p>Oversees Quality of Care (QOC) case identification, referral, coordination, and documentation ensuring timely escalation and coordination of complex or medically nuanced grievance and appeal cases.</p><p>Strengthens the clinical and regulatory integrity of Appeals &amp; Grievances (A&amp;G) operations by guiding staff in the application of medical necessity criteria, ensuring documentation quality, and providing expert regulatory interpretation. Interprets and applies Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and internal policy requirements related to grievance and appeal processes, ensuring operations maintain regulatory alignment. Serves as a subject-matter expert for regulatory interpretation, providing guidance to operational staff and leadership. Reviews, interprets, and implements regulatory updates that impact clinical or operational grievance and appeal workflows. Partners with Compliance and Legal to resolve regulatory inquiries related to clinical and operational case-handling requirements. Supports creation and revision of clinical and operational policies, SOPs, templates, letters, and decision-support tools.</p><p>Partners with cross-functional stakeholders to ensure proper handling of clinical and non-clinical cases. Coordinates cross-functional involvement in complex cases, including providers, delegates, plan partners, and medical directors. Supports operational teams in resolving regulatory or clinical issues that arise during case handling.</p><p>Oversees training and competency development for clinical operations staff, ensuring consistent understanding of medical necessity criteria, regulatory requirements, and decision-making standards. Identifies opportunities to enhance staff capability, accuracy, and regulatory alignment across clinical case-handling processes.</p><p>Oversees clinical case reporting and trend analysis, identifying patterns in clinical appeals, grievances, and QOC findings. Provides insights to leadership related to clinical drivers of grievances and appeals, opportunities for operational improvements, and service or quality risks.</p><p>Manages staff and the day-to-day activities in the department. Participates in the department budgeting process.&nbsp; Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team.</p><p>Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/ or executive management to define, prioritize, and develop projects and programs.</p><p>Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.</p><p>Responsible for overseeing and managing the budgets of their respective departments.</p><h4>Duties Continued</h4><p>Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval.</p><p>Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities.&nbsp; Ensures strong clinical judgment, regulatory understanding, and documentation discipline across the team.</p><p>Builds a culture of rigor, transparency, analytical curiosity, proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.</p><p>Perform other duties as assigned.</p><h4>Education Required</h4>Bachelor's Degree in Nursing or Related Field<h4>Education Preferred</h4>Master's Degree in Business Administration or Related Field<h4>Experience</h4><p><strong>Required:</strong></p><p>At least 6 years of experience working in managed care operations, quality assurance, audit readiness, compliance, or related regulatory roles.</p><p>At least 5 years of experience in leading, supervising and/or managing staff.</p><p>Experience in Medicaid, Medicare, and Commercial managed care lines of business.</p><p>Demonstrated experience overseeing quality assurance programs, internal controls, or audit readiness functions within a health plan or similar setting.</p><p>Strong experience with DHCS, DMHC, CMS, and NCQA requirements related to grievances, appeals, quality-of-care processes, and audit expectations.</p><p>Experience developing and managing corrective action plans and driving sustainable remediation.</p><p>Experience collaborating with delegated entities, plan partners, or subcontracted networks.</p><p>Experience leading teams, projects, initiatives, or cross-functional groups.</p><p><strong>Preferred:</strong></p><p>Experience with analytic dashboards and visualization tools (Power BI, Tableau).</p><h4>Skills</h4><p><strong>Required:</strong></p><p>Proven ability to lead universe submissions, mock audits, and regulatory audit responses.</p><p>Expert knowledge of regulatory requirements, audit processes, and quality assurance practices in managed care.</p><p>Strong analytical, problem-solving, and critical thinking skills, including ability to translate trends into corrective actions.</p><p>Ability to design, implement, and sustain standardized processes and internal control structures.</p><p>Exceptional written and verbal communication skills, including executive communication and the ability to translate trends and other findings into actionable recommendations.</p><p>Proficiency with Microsoft Office, case management systems, and reporting tools.</p><p>Strong people skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.</p><p>Strong attention to detail and ability to manage multiple priorities and tight deadlines.</p><p>Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.</p><p>Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.</p><p>Must have a deep understanding of financial principles.</p><p>Ability and exceptional knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.</p><p>Demonstrated ability to make informed decisions.</p><p>Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.</p><p>Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.</p><h4>Licenses/Certifications Required</h4>Registered Nurse (RN) - Active, current and unrestricted California License<h4>Licenses/Certifications Preferred</h4><h4>Required Training</h4><h4>Physical Requirements</h4>Light<h4>Additional Information</h4><p>This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.</p><p>This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned.</p><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market.&nbsp; The range is subject to change.</p><p><b>L.A. Care offers&nbsp;a wide range of benefits including</b></p><ul><li>Paid Time Off (PTO)</li><li>Tuition Reimbursement</li><li>Retirement Plans</li><li>Medical, Dental and Vision</li><li>Wellness Program</li><li>Volunteer Time Off (VTO)</li></ul><p><br><strong>Nearest Major Market: </strong>Los Angeles                                                                            <br><strong>Job Segment: </strong>                    Nursing, Registered Nurse, Medicare, Medicaid, Medical Research, Healthcare                                                    </p>

Senior Manager, Clinical and Regulatory Operations

<p><strong>Castle Biosciences Earns "Top Workplaces USA Award" for Phoenix, Pittsburgh, and Friendswood!</strong></p><p> Learn more at <a href="http://www.CastleBiosciences.com" target="_blank">www.CastleBiosciences.com</a></p><p><strong>Castle Biosciences Inc. </strong>is growing, and we are looking to hire a <strong>full-time Reimbursement, RCM Systems Supervisor working from our Friendswood, Texas, office location,</strong> with a start date of February 9, 2026. </p><p><strong>Why Castle Biosciences?</strong></p><p><strong>Exceptional Benefits Package:</strong></p><ul><li><strong>Excellent Annual Salary + 25%</strong><strong> Bonus Potential</strong></li><li><strong>20 Accrued PTO Days Annually + 10 Paid Holidays</strong></li><li><strong>401K with 100% Company Match up to 6%</strong></li><li><strong>3 Health Care Plan Options + Company HSA Contribution</strong></li><li><strong>Company Stock Grant Upon Hire</strong></li></ul><p><strong>A DAY IN THE LIFE OF A RCM Systems Supervisor</strong></p>As the RCM Systems Support Supervisor, you'll lead the daily operations of the RCM Systems Support and Payer Enrollment teams, ensuring work is completed accurately and on schedule. Your day will involve answering questions, resolving escalations, and guiding staff through system configuration, billing workflows, and payer requirements. You'll assist with configuration changes, workflow design sessions, and thorough regression testing to maintain system continuity. A key part of your role includes supporting nationwide payer enrollment and credentialing activities, troubleshooting documentation issues, and coordinating required submissions. You will collaborate closely with IT, reimbursement leadership, and external partners to address system or processing concerns. Throughout the day, you'll monitor work quality, maintain progress trackers, and communicate updates, risks, or barriers to leadership-helping drive efficient, compliant, and well‑supported revenue cycle operations.<p><strong>REQUIREMENTS</strong></p><ul><li>Bachelor's degree in computer science or related field is required, and/or equivalent combination of experience and education.</li><li>At least 3 years in revenue cycle systems management, managing /doing billing system configuration changes, maintenance, upgrades, and system testing and documentation.</li><li>At least 3 years of successfully managing processes and people.</li><li>Knowledge of laboratory medical insurance billing requirements and revenue cycle workflow preferred.</li><li>Experience in doing nationwide laboratory payer enrollment and credentialing; commercial payers and Medicaid.</li><li>Intermediate to advanced proficiency in Microsoft Excel, Word, PowerPoint, SharePoint, and Outlook.</li><li>Attention to detail and the ability to manage multiple priorities in a fast-paced ever-changing environment.</li><li>Strong analytical, problem‑solving, and critical‑thinking skills.</li><li>Ability to learn new skills quickly and apply them to daily job responsibilities.</li><li>Experience developing SOPs and process documentation.</li><li>Experience working with clearing houses.</li></ul><p>*<strong>Please see the full job description at the end of the job ad.</strong></p><p><strong>SCHEDULE</strong></p><ul><li>Monday - Friday, 8 AM - 5 PM working from our Friendswood, Texas office location. May consider remote candidates</li></ul><p><strong>READY TO JOIN OUR BIOTECH TEAM?</strong></p><p>We truly appreciate your time. If this feels like the right opportunity for you, we'd love for you to complete our <strong>mobile-friendly application.</strong> We're excited to learn more about you and look forward to connecting soon!</p><p><strong>Castle Biosciences Awards and Research Developments!</strong></p><p><strong>WORK AUTHORIZATION</strong></p><p><strong>All candidates must be legally authorized to work in the United States. Currently, Castle Biosciences does not sponsor H-1B visas, OPT, or employment-related visas.</strong></p><p><strong>ABOUT CASTLE BIOSCIENCES INC.</strong></p><p>At Castle, it all comes down to people. After all, disease doesn't just happen - it happens to people. We believe that disease management and treatment decisions can be better informed through a person's unique biology, which is revealed through the scientific rigor of our innovative, laboratory-developed tests. We are committed to empowering healthcare providers and patients with the goal of improved outcomes. </p><p>Every employee at Castle has an impact on patient care, and we work to ensure that everyone finds their work to be both <strong>challenging and rewarding</strong>. We behave with <strong>integrity</strong> and treat our colleagues with <strong>respect and kindness</strong>. Our culture fosters an <strong>environment of trust, transparency, and collaboration</strong>. We prioritize and encourage <strong>internal growth</strong> and <strong>professional development</strong>.</p><p>Castle Biosciences is an equal opportunity employer as to all protected groups, including protected veterans and individuals with disabilities. </p><p>If you have a disability and you believe you need a reasonable accommodation in order to search for a job opening or to submit an online application, please e-mail <strong><a href="mailto:ReasonableAccommodationsRequest@castlebiosciences.com" target="_blank">ReasonableAccommodationsRequest@castlebiosciences.com</a></strong>.</p><p>This email was created exclusively to assist disabled job seekers whose disability prevents them from being able to apply online. Only messages left for this purpose will be returned. Messages left for other purposes, such as following up on an application or technical issues not related to a disability, will not receive a response.</p><p>** No third-party recruiters, please</p>

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