Manager, Claims Research and Remediation

Job Category:
Claims

Department:
Claims Data and Support Services

Location:

Los Angeles, CA, US, 90017

Position Type:
Full Time

Requisition

Salary Range: $ (Min.) - $ (Mid.) - $ (Max.)

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low‑income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County’s vulnerable and low‑income communities and residents and to support the safety net required to achieve that purpose.

The Manager, Claims Research and Remediation manages L.A. Care’s specialized “Tiger Team” responsible for investigating, reconstructing, quantifying, and remediating the most complex and high‑risk claims issues across the enterprise. This includes deep‑diving root cause analysis (RCA), litigation‑related claims support, systemic defect reconstruction, mass adjustment planning, execution, and large‑scale remediation efforts required to mitigate legal, regulatory, or financial exposure.

The Manager serves as a trusted operational partner to cross‑functional key stakeholders by conducting high‑precision analyses, validating claim impacts across multiple time periods, creating audit‑ready documentation, and designing remediation strategies that reduce risk and recommend quality assurance protocols to ensure accuracy across the claims ecosystem.

The Manager manages and leads staff who research and remediate complex providers, contracts, benefit structures, retroactive policy changes, system defects, and multi‑year claim reviews. The position ensures deep analytical rigor, data integrity, quality control, and cross‑functional coordination in all remediation work.

The Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Participates and makes recommendations on the department’s strategic planning and/or long‑term decision‑making.

Drives L.A. Care’s most critical investigative and corrective work. Deals with the highest regulatory, financial, or legal exposure. Ensures that investigations are comprehensive, evidence‑based, and defensible, and that remediation actions are accurate, auditable, and sustainable. Leveraging analytics, structured project leadership, and strong cross‑functional collaboration, protects the organization while strengthening upstream processes and long‑term operational reliability.

Leads the investigation of complex issues involving benefit configuration errors, contract misinterpretation, pricing defects, authorization discrepancies, coding anomalies, or systemic system defects. Reconstructs claims outcomes across multiple adjudication cycles, benefit periods, and contract iterations to determine root cause and impact. Conducts multi‑layered RCA involving claims rules, configuration tables, provider contracts, Electronic Data Interchange (EDI) inputs, pricing logic, benefit grids, Utilization Management (UM) decisions, and historical system changes.

Develops complete audit trails documenting “what happened,” “why it happened,” and “how to prevent recurrence.”

Partners with Legal to support litigation research, discovery preparation, and exposure modeling. Conducts claims sampling, case reconstruction, data pulls, validation, and preparation of evidentiary claim packages. Provides operational insights and documentation required for regulators, external auditors, and legal proceedings. Works with Compliance to design corrective action plans and support enterprise readiness during regulatory reviews, inquiries, or settlements.

Partners with Claims Administration and Quality Assurance (QA) in the development of end‑to‑end remediation plans, including identification, retrieval, correction, reprocessing, and reconciliation of affected claims. Oversees multi‑layered remediation for retroactive…