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L.A. Care Health Plan · 1 day ago

Manager, Claims Quality Assurance

Los Angeles, CA

Full-time

Onsite

Senior Level

$102K/yr - $163K/yr

5+ years exp

L.A. Care Health Plan is the nation’s largest publicly operated health plan, dedicated to providing health coverage to low-income residents of Los Angeles County. The Manager, Claims Quality Assurance is responsible for leading the operational quality program to ensure high processing accuracy across the claims lifecycle, while managing staff and collaborating with cross-functional stakeholders.

FitnessGovernmentHealth Care

Responsibilities

Builds a disciplined quality review framework that increases first-pass accuracy, reduces preventable defects, strengthens upstream controls, and ensures consistent application of rules across the claims lifecycle

Oversees audits across the entire operational claims lifecycle including claim intake, data entry, adjudication, pricing, coding accuracy, benefit interpretation, provider contract application, and documentation

Monitors and validates adjustment processing, provider disputes resolutions, and post-payment quality outcomes tied to Payment Integrity remediation

Ensures quality reviews measure accuracy, consistency, and compliance with policies, benefit structures, provider contracts, coding standards, pricing methodologies, and regulatory expectations

Ensures QA findings are accurate, evidence-based, and actionable for operational leaders

Designs and oversees the claims QA audit methodology, including sampling standards, audit frequency, scoring tools, examiner scorecards, and quality thresholds

Co-leads claims components of mock audits for regulatory agencies, and related review bodies

Prepares audit universes, conducts sample reviews, organizes evidence, and ensures accuracy of documentation for internal/external audits

Ensures QA processes meet expectations for regulatory audit readiness

Conducts root-cause analysis on quality findings to identify systemic drivers behind defects or inconsistencies

Works with cross functional key stakeholders to implement and validate corrective actions

Confirms that corrective actions address underlying issues and reduce recurrence

Tracks error trending to identify early signals of operational or regulatory risk

Maintains claims QA guidelines, audit manuals, sampling methodologies, scoring rules, and documentation requirements

Develops quality dashboards, trend analyses, and quality scorecards for Core Administrative Operations leadership

Ensures quality results are communicated clearly, consistently, and with actionable recommendations

Monitors adherence to quality standards across examiners, analysts, and adjustment staff

Partners with Claims Administration to align QA results with workflow changes, training needs, and performance expectations

Coordinates with Configuration’s system QA team to align operational audit insights with system testing requirements (no ownership of configuration QA)

Works with Payment Integrity to validate accuracy of post-pay adjustments and ensure systemic issues are fed into preventive controls

Collaborates with Compliance & Training to ensure QA findings inform training content, SOP updates, and policy interpretation

Supports SVU and the Tiger Team by validating accuracy of complex claim reviews and identifying upstream contributors to identified issues

Establishes performance metrics, audit schedules, and competency expectations

Builds a culture grounded in analytical precision, data integrity, critical thinking, and investigative rigor

Capitalizes on metrics for proactive indicators of risks, issue identification, cross-functional communication, accountability, transparency, and execute continuous operational improvement

Manage staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others

Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval

Responsible for reporting, budgeting, and policy implementation

Perform other duties as assigned

Qualification

Claims auditingRegulatory audit preparationRoot-cause analysisClaims data analysisProvider contract interpretationQuality program designAnalytical skillsProject managementMicrosoft OfficeBudget managementStrategic planningInterpersonal skillsCommunication skillsTeam leadershipConflict resolution

Required

Bachelor's Degree

At least 5 years of experience claims operations, claims auditing, claims QA, or complex claims operational functions

At least 3 years of experience leading, supervising /managing staff

Experience leading teams, projects, initiatives, or cross-functional groups

Experience in Medicaid, Medicare, and Commercial managed care lines of business

Hands-on experience conducting claims testing or accuracy audits

Deep experience interpreting provider contracts, payment methodologies, and managed care benefit structures

Demonstrated experience with high complexity claims review and RCA

Experience supporting or preparing for regulatory audits (DMHC, DHCS, CMS)

Demonstrated experience analyzing claims defects and validating corrective actions

Deep understanding of standard claims processing systems and claims data analysis

Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing

Deep knowledge of claims adjudication, benefit structures, provider contracting, DoFR, pricing rules, and coding standards

Advanced analytical and root-cause analysis skills

Deep knowledge of relevant regulatory requirements

Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously; strong attention to detail

Ability to track and trend the metrics associated with auditor production

Proficient of Microsoft Office suite, including Word, Excel, Teams and PowerPoint

Highly collaborative and maintain a consultative style with ability to establish credibility quickly with all levels of management across multiple functional areas

Exceptional interpersonal, verbal, and written communication skills, including executive communication with ability to produce audit-ready documentation

Ability to present findings to various levels of management, and including stakeholders, across the organization

Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment

Ability to guide and support team members

Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision

Skilled in mediating disputes and resolving conflicts in a fair and constructive manner

Deep understanding of financial principles

Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation

Ability to make informed decisions

Strong verbal, written communication and presentation skills

Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges

Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals