Director of Claims

San Diego's largest Medicaid Health Plan"”is seeking an experienced Director of Claims to lead their claims operations and provider services. This pivotal role offers the opportunity to design, implement, and oversee systems that directly impact healthcare outcomes across the region.Position OverviewThe Director of Claims Administration will oversee claims handling systems, policies, and procedures while ensuring the accuracy, timeliness, and compliance of claims processing. They will also manage relationships with providers, supervise a team of direct and indirect reports, and serve as a key leader in maintaining CHG's reputation for operational excellence.Key ResponsibilitiesOperational Leadership: Oversee claims processing to ensure accurate and timely adjudication by managing systems, policies, and team performance. Continuously evaluate and refine operational processes to meet organizational goals.Provider Engagement: Interface with providers to resolve payment issues, offer billing instruction, and implement recommendations to improve claims processes. Handle escalated provider appeals and disputes with fairness and efficiency.System Oversight: Lead the configuration of the claims system, ensuring all contracts, fee schedules, and benefits are set up accurately across all lines of business.Compliance Management: Ensure adherence to federal and state regulations, including those from DHCS, DMHC, CMS, and Medicare Part D. Collaborate across departments to maintain compliance and operational integrity.Reporting and Analysis: Generate user-friendly inventory and production reports to support financial and organizational impact analysis.Team Development: Foster competency and compliance within the claims team through training, performance monitoring, and the implementation of a Quality Improvement Process (QIP).Organizational Integration: Participate in cross-departmental committees and workgroups to align claims operations with organizational objectives.The ideal candidate will possess:A BS/BA degree in a related field.5-7 years of claims processing experience, including 2-3 years of direct supervision of technical or professional staff.In-depth knowledge of HMO operations, medical coding, and state and federal HMO regulations (DHCS, DMHC, CMS).Application-level understanding of HIPAA, Privacy Act, and ERISA requirements.Familiarity with Medi-Cal claims processing, including third-party and workers' compensation claims.Experience with the QNXT claims processing system (preferred).Strong understanding of how claims operations interact with other departments and functional areas.The Perks:Competitive salary in the upper $100s.Comprehensive benefits, including employee-premium-covered Medical, Dental, and Vision insurance.Generous PTO package (19 days) and a mission-driven, collaborative work environment.This role is on-site in sunny San Diego, offering the opportunity to lead a high-performing team while contributing to CHG's mission of improving health outcomes for their community.Ready to make an impact? Apply today to join CHG and help redefine excellence in claims administration#INDDHSS#DirectorPay: $160,000.00 - $185,000.00 per yearBenefits:* 401(k)* Dental insurance* Health insurance* Paid time off* Vision insuranceWork Location: In person

Created: 2025-01-15