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L.A. Care Health Plan · 11 hours ago

Senior Manager, Claims Adjustments

Los Angeles, CA

Full-time

Onsite

Mid, Senior Level

$118K/yr - $188K/yr

6+ years exp

L.A. Care Health Plan is the nation’s largest publicly operated health plan, serving over 2 million members. The Senior Manager, Claims Adjustments is responsible for managing all adjustment-related operational workflows, ensuring accurate and compliant claim adjustments, and leading a team to drive performance that aligns with the company’s mission.

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Responsibilities

Manages all adjustment-related operational workflows, including provider disputes, escalated claim reviews, complex adjustments, and litigation-related claim support

Ensures that adjustment decisions are accurate, timely, consistent, and fully compliant with state, federal, and contractual requirements

Functions as the operational leader for all claim adjustments that exceed routine examiner responsibilities and require higher-level investigation or coordination

Leads a team of adjustment analysts and dispute specialists, building a culture of accuracy, documentation discipline, transparency, and initiative-taking issue identification

Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports

Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care

Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures

Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities

Manages daily operations for all non-routine claim adjustments, including escalated cases, complex pricing reviews, and benefit or authorization-related adjustments

Ensures that adjustments are accurate, compliant, and completed within regulatory and contractual timeframes

Oversees consistent application of payment rules, contract terms, and standardized work instructions

Builds and maintains clear adjustment pathways based on claim type, complexity, and regulatory requirements

Oversees provider disputes requiring adjustment, including root-cause analysis and documentation of findings

Ensures all provider adjustments meet Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), and contractual (TAT) requirements

Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/or executive management to define, prioritize, and develop projects and programs

Provides operational support for high-profile or complex provider inquiries involving reimbursement, coding, contract terms, or medical policy

Manages communication with cross-functional departments and/or teams when needed

Ensures all adjustments are documented accurately and consistently, supporting audit readiness

Partners with Compliance to validate adherence to regulatory standards and internal policies

Escalates potential compliance gaps or systemic issues that may require corrective action

Partners with Legal to support claim-level discovery, case review, and preparation of adjustment packages

Provides operational insight on benefit application, contract interpretation, and pricing methodology relevant to legal inquiries

Ensures adjustments completed in relation to litigation or legal review are precise and audit ready

Collaborates closely with cross-functional departments to resolve adjustment-related dependencies

Communicates root-cause drivers of adjustment volume and advocates for upstream corrections

Ensures adjustment processes are aligned with enterprise standards and system logic

Develops reports and dashboards tracking adjustment volume, turnaround performance, accuracy trends, and systemic issues

Identifies trends in adjustment drivers and collaborates on upstream solutions that reduce rework

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

Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions

Provides executive summaries for high-risk or high-complexity adjustment issues

Manages staff and the day-to-day activities in the department

Participates in the department budgeting process

Responsible for scheduling, training, performance, corrective actions, mentoring, developing of the team(s)

Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals

Mentors and develops staff, building technical and critical thinking skills across the team

Responsible for overseeing and managing the budgets of their respective departments

Builds a culture of rigor, transparency, analytical curiosity, initiative-taking issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement

Qualification

Claims ManagementRegulatory ComplianceTeam LeadershipAnalytical SkillsContract InterpretationBudget ManagementCommunication SkillsCritical ThinkingConflict ResolutionAttention to Detail

Required

Bachelor's Degree

At least 6 years of experience working in claims, provider disputes, adjustments, or related operational functions

At least 5 years of experience in leading, supervising and/or managing staff

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

Experience in interpreting provider contracts, payment methodologies, and managed care benefit structures

Experience managing complex claim review, root-cause evaluation, adhering to regulatory TAT requirements, and ensuring accuracy

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

Strong understanding of adjudication, coding, pricing, the application of Division of Financial Responsibility (DOFR) to claims processing, and managed care payment rules

An advanced knowledge of contractual pricing mechanisms for inpatient, outpatient, Long Term Care (LTC) and ancillary services

Knowledge of relevant regulatory requirements (DMHC, DHCS, CMS)

Strong analytical and decision-making skills for complex claim scenarios

Ability to provide reporting requirements based on processes and/or regulatory requirements

Proven critical thinking skills and ability to translate knowledge to the department

Strong people skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members

Strong attention to detail and ability to manage multiple priorities and tight deadlines

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

Must have a deep understanding of financial principles

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

Demonstrated ability to make informed decisions

Strong verbal, written communication, and presentation skills, including executive communication

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