Manager, Claims Compliance

Job Summary

The Manager, Claims Compliance is responsible for ensuring Core Administrative Operations meet federal, state, and contractual regulatory requirements. This position oversees regulatory interpretation, operational compliance monitoring, corrective action oversight, and the development and delivery of operational training across all claims-related functions.

Duties

Ensures that Core Administrative Operations has a strong and sustainable compliance foundation. Interprets regulatory guidance, identifies compliance risks, develops training that operationalizes regulatory changes, and builds documentation that ensures accuracy and audit readiness. Strengthens operational integrity, improves adherence to state/federal requirements, and equips staff with the knowledge and tools needed to process claims accurately and consistently through cross-functional collaboration, transparent communication, and structured oversight. Monitors compliance with regulatory agencies, NCQA, and contractual requirements related to claims processing, adjustments, disputes, configuration, and payment accuracy. Interprets new and updated regulations, determines operational impacts, and guides leaders in implementing compliant workflows across key stakeholders. Oversees compliance monitoring and internal validation activities, ensuring critical regulations (TATs, notices, interest, benefit/payment rules, documentation) are consistently met. Serves as subject-matter expert on regulatory and contractual requirements affecting claims and related administrative functions. Partners with the key stakeholders to ensure compliance findings are integrated into testing programs, CAP validation, and quality standards. Designs, implements, and oversees comprehensive operational training programs across cross-functional teams. Develops training curricula for benefit/authorization interpretation, regulatory updates, pricing/reimbursement requirements, provider contract terms, system logic impacts, and other operational topics. Ensures training incorporates regulatory expectations, audit findings, corrective action themes, and emerging rules. Maintains an enterprise training repository (SOPs, desk procedures, job aids, reference guides) to ensure consistent understanding and execution. Provides onboarding training, cross-training programs, and targeted training for new systems, regulatory changes, and operational enhancements. Partners with key stakeholders to ensure staff have the knowledge required to maintain accuracy in a highly regulated environment. Oversees creation, maintenance, and governance of policies, procedures, desk-level workflows, and job aids across Core Admin Ops. Ensures documentation is aligned with current regulatory requirements, contractual obligations, and operational processes. Maintains structured documentation approval processes and version control to support audit readiness and compliance transparency. Partners with operational leaders and QA to ensure procedures align with audit findings, corrective actions, and quality standards. Leads operational readiness planning for regulatory or contractual changes affecting claims payment, provider reimbursement, data requirements, notices, timelines, and related administrative rules. Collaborates with key stakeholders to identify impacts, design compliant solutions, and update training/materials. Develops and manages implementation plans for required changes, ensuring consistency across teams and sustainable compliance. Supports internal and external audits by preparing documentation, participating in sample review, and coordinating with QA and operational leaders. Tracks regulatory trends and proactively identifies potential compliance risks or exposure areas. Develops and oversees corrective actions related to compliance gaps, operational deficiencies, and audit findings. Ensures corrective actions incorporate training, policy updates, and process changes to drive sustainable improvement. Partners key stakeholders to validate Corrective Action Plan (CAP) effectiveness through testing, monitoring, and data-driven assessments. Tracks patterns of compliance gaps and collaborates with operational leaders to implement preventive improvements. Serves as the primary compliance advisor to operational leaders within cross-functional business units. Supports management with regulatory interpretation, operational analysis, compliance risks, and recommended mitigation strategies. Represents Claims Compliance in governance meetings, operational readiness discussions, and regulatory working groups. Partners with Analytics and operational reporting teams to monitor compliance metrics, operational adherence, and trend analyses. Manages, leads, trains, and develops a team responsible for training, documentation, compliance monitoring, and regulatory interpretation. Ensures staff maintain deep working knowledge of regulatory requirements and operational processes. Builds a culture grounded in data integrity, critical thinking, and supports proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement. Manage staff, including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others. Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Responsible for reporting, budgeting, and policy implementation.

Education & Experience

Education Required: Bachelor's degree in healthcare administration, business, or a related field. Education Preferred: Master's degree in healthcare administration, business, or a related field. Experience Required: At least 6 years of experience in claims compliance, regulatory oversight, or related experience in a managed care environment. At least 4 years of experience leading, supervising/managing staff. Experience leading teams, projects, initiatives, or cross-functional groups. Experience with claims processing, adjustments, payment methods, and associated core administrative operations. Experience in Medicaid, Medicare, and Commercial managed care lines of business. Experience developing training programs or documentation for claims or other administrative operations. Deep experience interpreting regulations, provider contracts, payment methodologies, and managed care benefit structures. Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing. 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. Experience Preferred: Licenses/Certifications Required: Licenses/Certifications Preferred: Required Training: 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, and Volunteer Time Off (VTO).