Manager, Claims Compliance

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.

Requirements

• Bachelor's Degree
• 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.

Benefits

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)