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L.A. Care Health Plan · 3 days ago

Manager, Claims Compliance

Los Angeles, CA

Full-time

Onsite

Senior Level

$118K/yr - $188K/yr

6+ years exp

L.A. Care Health Plan is the nation’s largest publicly operated health plan, dedicated to providing health coverage to low-income Los Angeles County residents. The Manager, Claims Compliance is responsible for ensuring compliance with federal, state, and contractual regulatory requirements within Core Administrative Operations, overseeing training, documentation, and operational readiness.

FitnessGovernmentHealth Care

Responsibilities

Ensures that Core Administrative Operations has a strong and sustainable compliance foundation

Interprets regulatory guidance, identifies compliance risks, develops training that operationalizes regulatory changes, and builds documentation that ensures accuracy and audit readiness

Strengthens operational integrity, improves adherence to state/federal requirements, and equips staff with the knowledge and tools needed to process claims accurately and consistently through cross-functional collaboration, transparent communication, and structured oversight

Monitors compliance with regulatory agencies, NCQA, and contractual requirements related to claims processing, adjustments, disputes, configuration, and payment accuracy

Interprets new and updated regulations, determines operational impacts, and guides leaders in implementing compliant workflows across key stake holders

Oversees compliance monitoring and internal validation activities, ensuring critical regulations (TATs, notices, interest, benefit/payment rules, documentation) are consistently met

Serves as subject-matter expert on regulatory and contractual requirements affecting claims and related administrative functions

Partners with the key stakeholders to ensure compliance findings are integrated into testing programs, CAP validation, and quality standards

Designs, implements, and oversees comprehensive operational training programs across cross functional teams

Develops training curricula for benefit/authorization interpretation, regulatory updates, pricing/reimbursement requirements, provider contract terms, system logic impacts, and other operational topics

Ensures training incorporates regulatory expectations, audit findings, corrective action themes, and emerging rules

Maintains an enterprise training repository (SOPs, desk procedures, job aids, reference guides) to ensure consistent understanding and execution

Provides onboarding training, cross-training programs, and targeted training for new systems, regulatory changes, and operational enhancements

Partners with key stakeholders to ensure staff have the knowledge required to maintain accuracy in a highly regulated environment

Oversees creation, maintenance, and governance of policies, procedures, desk-level workflows, and job aids across Core Admin Ops

Ensures documentation is aligned with current regulatory requirements, contractual obligations, and operational processes

Maintains structured documentation approval processes and version control to support audit readiness and compliance transparency

Partners with operational leaders and QA to ensure procedures align with audit findings, corrective actions, and quality standards

Leads operational readiness planning for regulatory or contractual changes affecting claims payment, provider reimbursement, data requirements, notices, timelines, and related administrative rules

Collaborates with key stakeholders to identify impacts, design compliant solutions, and update training/materials

Develops and manages implementation plans for required changes, ensuring consistency across teams and sustainable compliance

Supports internal and external audits by preparing documentation, participating in sample review, and coordinating with QA and operational leaders

Tracks regulatory trends and proactively identifies potential compliance risks or exposure areas

Develops and oversees corrective actions related to compliance gaps, operational deficiencies, and audit findings

Ensures corrective actions incorporate training, policy updates, and process changes to drive sustainable improvement

Partners key stakeholder to validate Corrective Action Plan (CAP) effectiveness through testing, monitoring, and data-driven assessments

Tracks patterns of compliance gaps and collaborates with operational leaders to implement preventive improvements

Serves as the primary compliance advisor to operational leaders within cross functional business units

Supports management with regulatory interpretation, operational analysis, compliance risks, and recommended mitigation strategies

Represents Claims Compliance in governance meetings, operational readiness discussions, and regulatory working groups

Partners with Analytics and operational reporting teams to monitor compliance metrics, operational adherence, and trend analyses

Manages, leads, trains, and develops a team responsible for training, documentation, compliance monitoring, and regulatory interpretation

Ensures staff maintain deep working knowledge of regulatory requirements and operational processes

Builds a culture grounded in data integrity, critical thinking, and supports proactive issue identification, cross-functional communication, accountability, transparency, and 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 complianceRegulatory oversightTraining developmentOperational managementManaged care experienceAnalytical skillsProject managementInterpersonal skillsMicrosoft OfficeBudget managementCommunication skillsProblem-solving skillsTeam leadershipConflict resolution

Required

Bachelor's Degree

At least 6 years of experience in claims compliance, regulatory oversight, or related experience in a managed care environment

At least 4 years of experience leading, supervising/managing staff

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

Experience with claims processing, adjustments, payment methods, and associated core administrative operations

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

Experience developing training programs or documentation for claims or other administrative operations

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

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

Experience supporting or preparing for regulatory audits (Department of Managed Health Care (DMHC), California Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS)) including corrective action planning

Strong operational understanding, and the ability to translate complex regulatory and contractual requirements into practical, operational execution

Deep knowledge of claims adjudication, benefit structures, provider contracting, DoFR, pricing rules, and coding standards (Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS)/ International Classification of Diseases (ICD)/ Diagnosis Related Group (DRG))

Strong understanding of federal/state regulatory frameworks governing claims

Exceptional ability to translate regulatory requirements into operational training and documentation

Strong analytical, problem-solving, and compliance monitoring skills

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

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

Proven ability to work collaboratively and influence across multiple functional areas

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

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

Must have a 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

Demonstrated 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