Job Title

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754 Compensation: $115,441 - $148,149 / year Department: Ops - Claims Ops Title: Senior Claims Manager, Claims Delegation Oversight Description The Senior Claims Manager, Claims Delegation Oversight, is responsible for the management and oversight of all Claims Delegation Audits, including health plan and governing agencies audits, such as DMHC, CMS, and DHCS. This role develops and executes department strategies, overall audit program, and audit process optimization, leveraging technology and data to improve quality and reduce cost. Together with the leadership team, the manager drives strategic planning, operational excellence, and accuracy of the claims process, ensuring compliance with regulations and contract requirements for Medicare, Commercial Exchange, and Medicaid service lines. The role also influences the Claims Delegation Oversight roadmap to ensure adherence to regulatory and internal guidelines for claims processing and adjudication. What You'll Do External Audit Planning, Execution & Support Develop and implement the operational strategy for driving all external audits for Prospect, ensuring audit planning, readiness, successful execution, CAP management, and improved audit score Lead, monitor, and oversee the end-to-end lifecycle of all external audits, including health plan audits, DMHC audits, CMS audits, etc. Create, monitor, and manage metrics and goals for successful execution and management of all external audits Ensure audit results are tracked, trended, reported, and communicated in a timely and effective manner Collaborate with the reporting team to deliver all universe listings accurately and on time Ensure all supporting documents are pulled and reviewed thoroughly prior to delivery Conduct a pre-audit for all external audits to gauge audit health and ensure compliance with internal and regulatory guidelines Lead root"‘cause analysis of deficiencies and develop remediation and process improvement solutions Work with claims operations to remediate pre"‘audit findings, including root"‘cause and prevention strategy development Manage corrective action plans with clear root"‘cause analysis and prevention plans, and review HP reports for accuracy Training & Development Review and approve cross"‘functional external audit process documentation, workflows, policies, job aids, and SOPs for completeness and accuracy Drive internal process adherence for creating and maintaining claims processes, workflows, policies, and SOPs Ensure adherence to all legislative, regulatory, and contractual requirements Oversee the training plan and strategy, measuring effectiveness and remediation strategy Identify training needs and gaps, ensuring timely and effective training for all team members Collaboration Build productive intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting/Finance, Recovery, Compliance, Configuration, Network Management, IT Ops, etc.) to enable timely problem resolution and drive operational excellence Collaborate with Claims Operations and Internal Audit teams to develop robust external audit strategies, root"‘cause analyses, and prevention plans for claim"‘related issues Work with IT & Data Analytics to develop tools for scorecards, dashboards, and reports Collaborate with Configuration and IT teams to improve system configuration and rules for accurate claims adjudication Recommend changes for system design, rules, and workflows affecting claims processing Contribute to claims testing and audit strategy development, providing timely feedback based on day"‘to"‘day findings Conduct special projects such as business analysis, strategic planning, and implementation for new acquisitions and changing business requirements Develop and execute strategic initiatives and programs to enhance existing functions and support corporate initiatives Staff Management Develop goals and objectives for the team and rollout strategy to achieve business outcomes Track key performance metrics, coach, and guide the team to success Recruit, develop, motivate, and lead the team to continuously improve performance Other duties as assigned Qualifications Solid understanding of DHCS, CMS rules and regulations governing claims adjudication Detailed knowledge of industry pricing methodologies (RBRVS, Medicare/Medi"‘Cal fee schedule, AP"‘DRG, APC, etc.) Knowledge of Medi"‘Cal, Medicare, and Medicaid program guidelines Working knowledge of NCQA, DHS, and HCFA standards Proficiency with CPT, HCPCS, DRG, REV, OPS, ASC, ICD10, CRVS, RBRVS, CMS, ICE for Health Plan, DMHC, and DHS fee schedules and third"‘party liability recovery Ability to coach and motivate employees to meet performance standards Ability to direct work, mediate interpersonal encounters, and follow legal guidelines and company policy Hands"‘on claims auditing experience with root"‘cause and prevention plan management Advanced knowledge of CMS and DMHC regulations for accurate claim processing Presentation and communication skills for managers, employees, and customers Advanced reasoning, problem"‘solving, and planning skills Strong multitasking, prioritization, and fast"‘paced work under minimal supervision Proficiency in Excel, including advanced spreadsheet creation and reporting Bachelor of Science or equivalent education required 3+ years of claims administration experience in a Health Plan/IPA/MSO setting 3+ years of experience with Health Plan Audit Delegation oversight Proven success in improving process metrics, cost reduction, and efficiency Demonstrated leadership, coaching, and mentoring experience Strong decision"‘making, influencing, and analytical skills Extensive knowledge of claims processing guidelines and payment systems You're Great for the Role If 3+ years of experience in people leadership Experience with EzCap, IDX, Cotiviti, Burgess Experience with clearinghouses such as Office Ally Experience managing offshore vendors Core system implementation experience Core system configuration experience Environmental Job Requirements and Working Conditions Hybrid work structure: both office and home weekly if living within 35 miles of the office at 1600 Corporate Center Dr., Monterey Park, CA 91754 The target pay range for this role is $115,440.56 - $148,148.72, determined by location and experience Astrana Health is an Equal Employment Opportunity and affirmative action employer. We do not discriminate based upon race, religion, color, national origin, gender, sexual orientation, gender identity, age, veteran status, or disability. All employment is based on qualifications, merit, and business need. If you require assistance due to a disability, please email for accommodations. Additional Information: The job description does not constitute an employment agreement and may be changed by the employer as needs evolve. #J-18808-Ljbffr