Manager, Claims Strategy & Operations Governance

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05-Claims French Camp, CA, US

2 days ago Requisition

Salary Range: $ To $ Annually

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

This is a remote position. Must reside in California, preferably in our service area.

What You Will Be Doing:

Under general direction, the Manager, Claims Strategy & Operations Governance is responsible for leading and integrating the governance, operational strategy, quality assurance, and recovery functions that support Claims Operations at the enterprise level. The role strengthens accountability, enhances visibility, and improves coordination across claims-related functions, including Claims Operations, Configuration, Provider Disputes, Adjustments, Recovery, QA, Training, and other functional teams. This position provides direct supervisory oversight of Quality Assurance and Recovery/Payment Integrity, while maintaining dotted ‑ line governance oversight of Claims Operations, Provider Disputes (PDR), Adjustments, Training, and related operational areas.

The manager ensures enterprise alignment, supports transformation activities, identifies operational risks, maintains governance infrastructure, and drives readiness for audits, regulatory requirements, and cross-functional initiatives. The work is highly complex and requires independent judgment, strategic thinking, strong communication skills, and an ability to influence across multiple levels without direct authority.

Analysts

Clerks (if aligned under QA or Recovery)

Essential Functions:

• Develops strategic and operational plans that align departmental objectives with enterprise-wide priorities; monitors progress and implements appropriate interventions.
• Establishes and maintains governance infrastructure for Claims Operations and related functions, including meeting cadence, reporting packages, dependency mapping, dashboards, initiative logs, and action item follow-through.
• Provides dotted ‑ line governance oversight of Claims Operations, including performance monitoring, priority alignment, issue escalation tracking, and operational readiness assessment.
• Directly oversees Quality Assurance, including audit processes, quality metrics, error trends, and corrective action plans to support quality and compliance improvements.
• Owns Recovery / Payment Integrity programs, including audit oversight, financial and operational reporting, savings validation, vendor coordination, regulatory compliance, and execution readiness.
• Facilitates alignment across Claims Operations, Configuration, Provider Disputes, Adjustments, Recovery, QA, Training, and other functional partners to ensure cohesive workflow design, coordinated execution, and unified problem-solving
• Coordinates transformation initiatives across claims-related functions, including workflow redesign, stabilization efforts, reporting modernization, recovery modernization, and operational readiness activities.
• Develops and maintains governance reporting packages, executive summaries, performance dashboards, and initiative tracking documentation to support leadership visibility and decision-making.
• Identifies operational, regulatory, and cross-functional risks; recommends mitigation strategies and supports the implementation of long-term controls.
• Oversees development, implementation, and maintenance of documentation including workflows, procedures, routing rules, governance logs, dependency maps, and operational frameworks.
• Serves as escalation point for complex claims, regulatory, recovery, and quality issues; researches concerns, facilitates resolutions, and coordinates communication with leadership.
• Collaborates with internal teams to prepare for regulatory audits and external reviews; supports readiness, documentation preparation, corrective action plan monitoring, and cross-functional follow-through.
• Supports fraud, waste, and abuse prevention efforts through coordinated analytics, issue identification, and operational escalation processes.
• Supervises quantitative and qualitative analyses across QA, Recovery, and governance areas; interprets data, develops insights, and recommends process improvements.
• Partners with Training and other stakeholders to support readiness, operational training needs, and workflow…