L.A. Care Health Plan · 1 day ago
Director, Claims Administration
Los Angeles, CA
Full-time
Onsite
Director/Executive
$135K/yr - $216K/yr
7+ years expL.A. Care Health Plan is the nation’s largest publicly operated health plan, created to provide health coverage to low-income residents of Los Angeles County. The Director, Claims Administration is responsible for overseeing the claims ecosystem, ensuring accurate and compliant processing while leading a team to foster accountability and operational integrity.
FitnessGovernmentHealth Care
Responsibilities
Translates organizational expectations into disciplined operational execution by creating predictable workflows, establishing strong preventative control environments, and ensuring that claims processing is accurate, timely, and complaint
Strengthens upstream quality, improves consistency through standardized processes, ensures rigorous adherence to regulatory and contractual requirements, and supports an operational model that aims to remove rework, prevents defects, and supports high-performing administrative operations
Through ownership of regulatory compliance and audit readiness perspective, provides strategic and operational leadership for all aspects of claims adjudication across all lines of business
Monitors daily, weekly, and monthly production performance to ensure accuracy, timeliness, and regulatory compliance
Oversees examiner productivity models, workload balancing, Quality Assurance performance, and inventory trending to ensure strong operational predictability
Ensures benefit, authorization, eligibility, and provider data issues are resolved quickly and consistently, with emphasis on preventing repeat defects
Supports enterprise initiatives requiring claims operational expertise
Leads all adjustment workflows, including escalations, provider disputes, general adjustments, and litigation-related claims review
Ensures all regulatory turnaround times (TATs) and provider/member notice requirements are consistently met, documented, and monitored
Services and the operational escalation point for high-visibility or high-complexity claim issues, including those involving regulators, legal, provider groups, or executive leadership
Develops standardized adjustment pathways that improve cycle time and reduce manual rework
Establishes and leads the Service Validation Unit (SVU) to function in a strategic, proactive and preventative manner by independently validate that billed services were authorized, medically supported, accurately represented, and provided/received prior to payment
Ensures SVU findings translate into upstream, corrections, system or process improvements, and improved preventive controls
Develops and leads initiatives to improve first-pass accuracy, reduce rework, shorten cycle time, and advance operational maturity
Participates in and partners through quality review processes to ensure adherence to regulatory and contractual processing standards
Oversees root-cause analysis of defects or variances, ensuring permanent corrective actions and improved upstream controls
Partners with stakeholder departments on regulatory reviews, corrective actions, and audit responses
Ensures the accuracy and timeliness of responses to regulators and external partners
Directs production, quality, and operational performance reporting, identifying trends, risks, and improvement opportunities
Ensures reporting supports proactive decision-making and enables early identification of potential inventory or compliance risks
Partners to establish/refine dashboards for visibility into accuracy, timeliness, adjustments, disputes, and SVU outcomes
Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees
Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals
Develops, and manages budgets, utilizing resources effectively
Conducts strategic planning to utilize resources in order to meet current and future departmental and Enterprise-wide goals
Identifies and actualizes enhancements to support company vision
Develops and maintains relationships with key stakeholders
Leads discussions on policy operationalization and oversees key policy perspective sharing
Ensures strong technical capability, a culture of accountability, and consistent performance
Fosters a culture of proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement
Performs additional duties as assigned
Qualification
Required
Bachelor's Degree
At least 7 years of healthcare claims (Medicare, Medicaid, and Commercial) experience
At least 5 years of experience leading, supervising and/or managing staff
Experience in Medicaid, Medicare, and Commercial managed care lines of business
Demonstrated experience leading claims adjudication, adjustments, disputes, escalations, and related functions
Extensive experience interpreting provider contracts, payment methodologies, and managed care benefit structures
Experience handling complex claim review, root-cause evaluation, adhering to regulatory timeliness requirements, and ensuring accuracy
Significant experience administering quality review programs and implementing sustainable operational improvements
Experience supporting litigation, state or federal inquiries, and regulatory audits
Demonstrated experience with high complexity claims review and RCA
Strong understanding of managed care contracts, benefit structures, payment methodologies, and authorization requirements
Strong interpersonal leadership skills and an ability to motivate and develop talent while driving accountability
Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing
Extensive knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD)-10, DRG/ Ambulatory Payment Classification (APC), and pricing methodologies
Deep study and understanding of managed care contracts and payment methodologies and provide contract interpretation
Strong project leadership and management skills required; ability to manage multiple priorities, complex workflows, and high-volume environments
Proficiency with Microsoft Office and data/reporting tools
Exceptional presentation skills, written and verbal communication skills, including executive communication skills with the ability to produce audit-ready documentation
Must be highly collaborative and maintain a consultative style with ability to establish credibility quickly with all levels of management across multiple functional areas
Must be able to present findings to various levels of management, across all organizations
Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization
Demonstrated ability to make sound and timely decisions
Demonstrated ability to adapt to changing situations and adjust strategies accordingly
Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change
Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment
Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations
Preferred
Master's Degree in Business Administration or Related Field
Experience leading a service validation or similar preventive quality/control unit
Certified Professional Coder (CPC)
Benefits
Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)
Company
L.A. Care Health Plan
L.A. Care’s mission is to provide access to quality health care for L.A.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Melanie Rainer
Chief Strategy and Transformation Officer
Recent News
2026-01-17
MarketScreener
2025-08-27
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