Director, Claims Administration; Director II

Director, Claims Administration (Director II) – Cal Optima

Join Us in this Amazing Opportunity

The Team You'll Join

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, review and apply today to help us build healthier communities for all.

More About the Opportunity

Join us as a Director, Claims Administration (Director II) to shape the future of healthcare as part of our Claims Administration team. This position has been approved for Partial Telework
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If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

The Director of Claims Administration leads the development and daily management of the operations and processing teams. You will develop and implement a strategic plan for claims operations, including growth planning, policy/standards development, budgeting, quality assurance, and efficiency improvements. We are building a stronger, more equitable health system.

Your Contributions To the Team:

• 40% - Leadership Functions
• Cultivates and promotes a mission-driven culture of high-quality performance with a member focus on customer service, consistency, dignity and accountability.
• Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team to support short- and long-term goals.
• Directs all aspects of claims operations and processing activities; accountable for the performance of the Claims Operations, Training, Adjustment and Customer Service teams.
• Maintains policies, procedures and standards for all department activities.
• Ensures adherence to Medi-Cal, Medicare and Covered California Plan policies and procedures for claims.
• Leads direct reports and ensures ongoing knowledge and skill development for all staff.
• Serves as primary back up for the Director of Operations Systems Configuration.
• Hires, manages, trains, supports, develops and evaluates direct reports.
• Performs ongoing staff and workflow analysis; plans to ensure adequate staffing for the Claims operational teams.
• Implements efficiency improvements such as streamlined processes and increased claim automation.

5% - Program Oversight

• Serves as subject matter expert in evaluating and assessing the business impact of new legislation, processes and products, and in implementing corporate-wide projects.
• Serves as lead authority on claims processing and collaborates with other department leadership on projects and impact assessments.
• Partners with other departments to ensure performance objectives and policies are met.
• Works with Sr Director of Claims to develop and implement strategic plans for claims inventory, quality, cycle time and budget.
• Assesses impact of new business/technologies; coordinates with senior leadership to align operations with organizational goals.
• Collaborates with Utilization Management, Medical Management and IT for system functionality.
• Provides reports to Contracting; assists with claims information for future contracting.
• Oversees DHCS All Plan Letter updates for benefit, claims guidelines, codes and fee schedules for Medi-Cal; oversees implementation and automation in Facets.
• Develops and manages overall operations and budget to support department and corporate initiatives.
• Develops scope of work documents for vendor support.
• Coordinates cross-department projects; implements detailed project plans and champions process improvement.

5% - Completes other projects and duties as assigned.

Do You Have What the Role Requires?

• Bachelor's degree in business administration or related field plus 7 years of experience in claims administration; equivalent education/experience may qualify.
• 5 years of progressive leadership experience, including direct supervision.

You'll Stand Out More If You Possess the Following:

• Master's degree.
• Experience managing claims for a large health plan.
• Experience with HMO, Medi-Cal/Medicaid, Medicare and commercial insurance or relevant government/public service…