Institutional Claims Manager

About the role

We’re seeking an experienced Institutional Claims Manager to oversee all aspects of claims operations across professional, facility, and institutional lines of business under Knox-Keene full-risk arrangements. This role ensures compliance with regulatory and health plan requirements, including DMHC, CMS, and internal network policies for Choice Physicians Network (CPN), RINCON, and affiliated groups.

Responsibilities

• Lead and support the claims team in daily operations
• Perform performance monitoring
• Oversight of appeals and PDRs
• Workflow optimization
• Collaborate across departments to drive operational excellence
• Provide oversight in the absence of senior leadership
• Maintain accuracy, efficiency, and regulatory integrity within all claims processes

Requirements

• Strong leadership skills
• Analytical skills
• Compliance skills

Qualifications

• Experience in claims management
• Knowledge of Knox-Keene full-risk arrangements
• Understanding of DMHC, CMS, and internal network policies

Skills

• Excellent communication and collaboration skills
• Ability to manage multiple priorities effectively
• Proficiency in regulatory compliance

Benefits

• Professional development opportunities
• Competitive compensation package
• Flexible work schedule

Pay

Commensurate with experience

Schedule

Varies based on department needs