Claims Leadership and Operations Manager

6 days ago


Los Angeles, California, United States L.A. Care Health Plan Full time

L.A. Care Health Plan, the nation's largest publicly operated health plan, is seeking a skilled Claims Supervisor to join our team.

Job Summary

The successful candidate will work closely with the Claims Manager to oversee daily operations, ensuring high-quality performance and compliance with state and federal regulations.

This role requires managing new program implementations, system updates, and maintaining expertise in national and state-wide standards for claims processes.

The ideal candidate will have a strong background in claims examination, preferably with experience working with medical facility claims and high-dollar claims.

In addition to technical skills, this role demands exceptional leadership, communication, and coaching abilities to build effective teams and drive results.

Key Responsibilities

  1. Supervise and develop procedures to achieve quality goals and production levels within the department.
  2. Maintain accurate tracking and trending of metrics associated with claims adjudication.
  3. Prepare and present written and verbal reports on complex problem areas and recommend corrective actions.
  4. Provide guidance and training to staff, including mentoring and cross-training.
  5. Ensure compliance with company policies, laws, and regulations.

Requirements

  • Bachelor's Degree in Business or Healthcare Related Field (equivalency accepted).
  • At least 3 years of experience as a claims examiner, preferably with medical facility claims and high-dollar claims.
  • 2+ years of supervisory/management experience, with equivalency through L.A. Care Management Certificate Training Program.
  • Extensive experience in handling claims appeals, communicating with external providers, and working with Provider Dispute Resolution (PDRs).
  • Strong understanding of healthcare code sets, familiarity with DRG pricing, and proficiency in Microsoft Word and Excel.

About Us

L.A. Care Health Plan offers a competitive salary range: $77,265 - $100,445 per year, depending on qualifications and experience. We provide a comprehensive benefits package, including paid time off, tuition reimbursement, retirement plans, medical, dental, and vision insurance, wellness programs, and volunteer time off.

We strive to create a diverse and inclusive work environment where employees feel valued and empowered to contribute their best. If you're passionate about delivering high-quality patient care and committed to excellence, we encourage you to apply for this exciting opportunity.



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