Bayside Solutions ยท 5 days ago
Claims Director
Martinez, CA
Contract
Hybrid
Lead/Staff, Director/Executive
$135K/yr - $156K/yr
5+ years expBayside Solutions is seeking a Claims Director who will work closely with executive leadership and cross-functional partners to align claims operations. The role is accountable for claims adjudication, payment integrity, regulatory compliance, and vendor oversight across Medi-Cal, Medicare, and commercial lines of business.
Information TechnologyStaffing AgencyTelecommunicationsVirtual Reality
No H1B
Responsibilities
Brings extensive experience leading health plan claims operations within a managed care environment, including responsibility for complex, high-volume systems
Demonstrates deep understanding of Medi-Cal and Medicare program requirements, including claims payment policy, audits, and regulatory oversight
Able to translate regulatory requirements and organizational priorities into sustainable operational strategies
Clearly conveys complex claims, financial, and compliance issues to executive leadership, staff, providers, and external partners
Proactively identifies operational risks and implements improvements that enhance accuracy, timeliness, and provider experience
Builds strong working relationships across finance, compliance, IT, utilization management, and external vendors
Exercises sound judgment in managing confidential, sensitive, and high-risk matters
Invests in leadership development, succession planning, and workforce stability
Providing leadership and oversight of all claims operations, including claims adjudication, adjustments, payment integrity, and recovery activities
Setting departmental strategy, goals, policies, and performance expectations aligned with our mission and regulatory obligations
Directing, coaching, and evaluating managers and supervisors responsible for daily claims operations
Overseeing third-party administrators, clearinghouses, and other claims-related vendors, including contract performance and issue resolution
Directing the use and optimization of Epic Tapestry for claims adjudication, payment rules, edits, and reporting, and ensuring system changes are appropriately tested, documented, and implemented
Implementing a claims editing software and establishing workflows to ensure payment integrity
Ensuring full compliance with federal, state, and local regulations, including DHCS, DMHC, and CMS requirements
Establishing and monitoring key performance indicators related to claims timeliness, accuracy, financial controls, and regulatory compliance
Serving as the primary liaison for claims-related matters with providers, county partners, auditors, and regulatory agencies
Representing our company at DHCS, CMS, and DMHC audits
Identifying operational risks, audit findings, and systemic issues, and ensuring timely corrective action and reporting to executive leadership
Collaborating with Provider Relations, Contracts, Finance, Compliance, Utilization Management, IT, and Quality divisions to support integrated operations and organizational objectives
Leading initiatives related to system enhancements, policy updates, and process redesign to improve claims efficiency and transparency
Qualification
Required
Achieving organizational and regulatory goals through strong operational leadership and accountability
Interpreting and applying complex laws, regulations, and guidance
Taking responsibility for outcomes and ensuring follow-through across teams
Maintaining composure and sound judgment under pressure and competing priorities
Effectively communicating complex information to executive and external audiences
Guiding the effective use of claims and payment systems to support operational performance, data integrity, and regulatory requirements, while partnering with IT on system enhancements and upgrades
Possession of a Bachelor's degree from an accredited college or university with a major in business administration, finance, accounting, or a closely related field
Five (5) years of full-time or its equivalent experience as an administrator or manager in a health care organization, at least three (3) years of which must have been in either a patient financial services, patient business services, patient accounting, or insurance billing and collections
Certified Healthcare Financial Professional (CHFP) issued by the Healthcare Finance Management Association (HFMA)
Certified Patient Account Manager (CPAM)
Certified Clinic Account Manager (CCAM) certifications issued by the American Association of Healthcare Administrative Management (AAHAM)
Certified Patient Account Technician (CPAT)
Certified Clinic Account Technician (CCAT), combined with an additional four (4) years of qualifying experience, can be substituted for the required education
Preferred
Claims Operations Leadership
Managed Care Claims Administration
Claims Adjudication and Adjustments
Payment Integrity and Recovery
Medi-Cal and Medicare Claims
Commercial Claims Operations
Regulatory Compliance (CMS, DHCS, DMHC)
Claims Audits and Payment Policy
High-Volume Claims Systems
Epic Tapestry Optimization
Claims Editing Software
Vendor and TPA Oversight
Clearinghouse Management
Operational Strategy and Risk Management
Financial Integrity and Controls
Claims KPIs and Reporting
Provider Relations and Experience
Cross-Functional Collaboration
IT and Systems Integration
Process Improvement and System Enhancements
Executive and Regulatory Communication
Audit Representation and Corrective Action
Leadership Development and Workforce Management
Healthcare Financial Operations
Patient Financial Services
Insurance Billing and Collections
CHFP
CPAM
CCAM
CPAT
CCAT
Company
Bayside Solutions
Bayside Solutions is a staffing and recruiting company offering IT, telecom, and scientific staffing services.
51-200 employees
Funding
Current Stage
Growth StageLeadership Team
B
Bob Klotz
Founder
Company data provided by crunchbase