Director, Claims Administration

Job Summary

The Director, Claims Administration, governs enterprise outcomes and risk controls, introducing a preventative orientation and regulatory accountability. 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).

Duties

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 compliant. 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, prevent defects, and support high-performing administrative operations. 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. Monitors daily, weekly, and monthly production performance to ensure accuracy, timeliness, and regulatory compliance. Oversees examiner productivity models, workload balancing, Quality Assurance performance, and inventory trending to ensure strong operational predictability. Ensures benefit, authorization, eligibility, and provider data issues are resolved quickly and consistently, with emphasis on preventing repeat defects. Supports enterprise initiatives requiring claims operational expertise. Leads all adjustment workflows, including escalations, provider disputes, general adjustments, and litigation-related claims review. Ensures all regulatory turnaround times (TATs) and provider/member notice requirements are consistently met, documented, and monitored. 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. Establishes and leads the Service Validation Unit (SVU) to function in a strategic, proactive and preventative manner by independently validating that billed services were authorized, medically supported, accurately represented, and provided/received prior to payment. Ensures SVU findings translate into upstream, corrections, system or process improvements, and improved preventive controls. Develops and leads initiatives to improve first-pass accuracy, reduce rework, shorten cycle time, and advance operational maturity. Participates in and partners through quality review processes to ensure adherence to regulatory and contractual processing standards. Oversees root-cause analysis of defects or variances, ensuring permanent corrective actions and improved upstream controls. Partners with stakeholder departments on regulatory reviews, corrective actions, and audit responses. Ensures the accuracy and timeliness of responses to regulators and external partners.

Education Required

- At least 7 years of healthcare claims (Medicare, Medicaid, and Commercial) experience. - At least 5 years of experience leading, supervising and/or managing staff. - Experience in Medicaid, Medicare, and Commercial managed care lines of business. - Demonstrated experience leading claims adjudication, adjustments, disputes, escalations, and related functions. - Extensive experience interpreting provider contracts, payment methodologies, and managed care benefit structures. - Experience handling complex claim review, root-cause evaluation, adhering to regulatory timeliness requirements, and ensuring accuracy. - Significant experience administering quality review programs and implementing sustainable operational improvements. - Experience supporting litigation, state or federal inquiries, and regulatory audits. - Demonstrated experience with high complexity claims review and RCA.

Education Preferred

- Experience leading a service validation or similar preventive quality/control unit.

Experience

- At least 7 years of healthcare claims (Medicare, Medicaid, and Commercial) experience. - At least 5 years of experience leading, supervising and/or managing staff. - Experience in Medicaid, Medicare, and Commercial managed care lines of business. - Demonstrated experience leading claims adjudication, adjustments, disputes, escalations, and related functions. - Extensive experience interpreting provider contracts, payment methodologies, and managed care benefit structures. - Experience handling complex claim review, root-cause evaluation, adhering to regulatory timeliness requirements, and ensuring accuracy. - Significant experience administering quality review programs and implementing sustainable operational improvements. - Experience supporting litigation, state or federal inquiries, and regulatory audits. - Demonstrated experience with high complexity claims review and RCA.

Skills

- Strong understanding of managed care contracts, benefit structures, payment methodologies, and authorization requirements. - Strong interpersonal leadership skills and an ability to motivate and develop talent while driving accountability. - Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing. - 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. - Deep study and understanding of managed care contracts and payment methodologies and provide contract interpretation. - Strong project leadership and management skills required; ability to manage multiple priorities, complex workflows, and high-volume environments. - Proficiency with Microsoft Office and data/reporting tools. - Exceptional presentation skills, written and verbal communication skills, including executive communication skills with the ability to produce audit-ready documentation. - Must be highly collaborative and maintain a consultative style with ability to establish credibility quickly with all levels of management across multiple functional areas. - Must be able to present findings to various levels of management, across all organizations. - Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization. - Demonstrated ability to make sound and timely decisions. - Demonstrated ability to adapt to changing situations and adjust strategies accordingly. - Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. - Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations.

Licenses/Certifications Required

- Licenses/Certifications Required

Licenses/Certifications Preferred

- Licenses/Certifications Preferred

Required Training

- Required Training

Physical Requirements

- Physical Requirements

Additional Information

- Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. - L.A. Care offers a wide range of benefits including - Paid Time Off (PTO) - Tuition Reimbursement - Retirement Plans - Medical, Dental and Vision - Wellness Program - Volunteer Time Off (VTO)