Sr. Manager - Claims Delegation Audit

About the role

The Senior Claims Manager, Claims Delegation Oversight, manages and oversees all Claims Delegation Audits, including health plan and governing agencies audits such as DMHC, CMS, and DHCS. This role develops and executes department strategies, leads audit processes, and ensures compliance with regulations and contract requirements.

Responsibilities

• Own the end-to-end strategy and execution of all external audits (e.g., CMS, DMHC, health plan audits)
• Lead audit planning, pre-audit readiness reviews, execution, issue tracking, and final reporting
• Establish and monitor audit metrics, scorecards, and dashboards; ensure timely, accurate communication of results
• Oversee corrective action plan (CAP) management, including root cause analysis, remediation, and prevention strategies
• Partner with Claims Operations to ensure audit findings are remediated promptly and sustainably
• Review and approve audit-related policies, procedures, workflows, job aids, and SOPs for accuracy and regulatory compliance
• Identify training gaps, oversee training strategy and delivery, and measure training effectiveness
• Cross-functional collaboration & process improvement: collaborate with internal partners to resolve issues and drive operational excellence
• Lead or support special projects, including new business implementations, business analyses, and strategic initiatives

Qualifications

• Bachelor’s degree (BA/BS) or equivalent combination of education and experience
• At least 3 years of claims administration experience within a Health Plan, IPA, or MSO environment
• At least 3 years of experience supporting or overseeing health plan and delegation audits
• At least 3 years of people leadership experience, including coaching and performance management
• Hands-on claims auditing experience, including root cause analysis and corrective action management
• Advanced knowledge of CMS, DHCS, DMHC, Medicare, Medi-Cal, and Medicaid regulations impacting claims adjudication
• Proficiency in Excel, including creating and maintaining reports and data summaries
• Highly organized, adaptable, and able to prioritize in a fast-paced environment with minimal supervision
• Proven ability to lead, coach, and motivate teams toward defined performance goals
• Strong analytical, problem-solving, and decision-making skills

Skills

• Master's Degree
• Experience with claims systems and tools (e.g., EzCap, IDX, Cotiviti, Burgess)
• Familiarity with clearinghouses (e.g., Office Ally), core system implementation, and configuration

Benefits

Our organization offers a hybrid work structure where employees can work both in the office and from home, depending on their preference and location. The office is located at 1600 Corporate Center Dr., Monterey Park, CA 91754. The national target pay range for this role is $125,000 - $140,000, with actual compensation determined based on geographic location, experience, and other job-related factors.

Pay

$125,000 - $140,000 / year

Schedule

Hybrid work structure, combining office and remote work.