Claims Director

W2 Contract-to-Hire

Salary Range: $135,200 - $156,000 per year

Location: Martinez, CA - Hybrid Role

Job Summary:

The Claims Director works closely with executive leadership and cross-functional partners to align claims operations, with accountability for claims adjudication, payment integrity, regulatory compliance, and vendor oversight across Medi-Cal, Medicare, and commercial lines of business. This role ensures claims operations support member access, provider relationships, and the financial integrity of the health plan.

Duties and Responsibilities:

• Brings extensive experience leading health plan claims operations within a managed care environment, including responsibility for complex, high-volume systems
• Demonstrates deep understanding of Medi-Cal and Medicare program requirements, including claims payment policy, audits, and regulatory oversight
• Able to translate regulatory requirements and organizational priorities into sustainable operational strategies
• Clearly conveys complex claims, financial, and compliance issues to executive leadership, staff, providers, and external partners.
• Proactively identifies operational risks and implements improvements that enhance accuracy, timeliness, and provider experience.
• Builds strong working relationships across finance, compliance, IT, utilization management, and external vendors
• Exercises sound judgment in managing confidential, sensitive, and high-risk matters.
• Invests in leadership development, succession planning, and workforce stability
• Providing leadership and oversight of all claims operations, including claims adjudication, adjustments, payment integrity, and recovery activities
• Setting departmental strategy, goals, policies, and performance expectations aligned with our mission and regulatory obligations
• Directing, coaching, and evaluating managers and supervisors responsible for daily claims operations
• Overseeing third-party administrators, clearinghouses, and other claims-related vendors, including contract performance and issue resolution
• Directing the use and optimization of Epic Tapestry for claims adjudication, payment rules, edits, and reporting, and ensuring system changes are appropriately tested, documented, and implemented
• Implementing a claims editing software and establishing workflows to ensure payment integrity
• Ensuring full compliance with federal, state, and local regulations, including DHCS, DMHC, and CMS requirements
• Establishing and monitoring key performance indicators related to claims timeliness, accuracy, financial controls, and regulatory compliance
• Serving as the primary liaison for claims-related matters with providers, county partners, auditors, and regulatory agencies
• Representing our company at DHCS, CMS, and DMHC audits
• Identifying operational risks, audit findings, and systemic issues, and ensuring timely corrective action and reporting to executive leadership
• Collaborating with Provider Relations, Contracts, Finance, Compliance, Utilization Management, IT, and Quality divisions to support integrated operations and organizational objectives
• Leading initiatives related to system enhancements, policy updates, and process redesign to improve claims efficiency and transparency.

Requirements and Qualifications:

• Achieving organizational and regulatory goals through strong operational leadership and accountability
• Interpreting and applying complex laws, regulations, and guidance
• Taking responsibility for outcomes and ensuring follow-through across teams
• Maintaining composure and sound judgment under pressure and competing priorities
• Effectively communicating complex information to executive and external audiences.
• Guiding the effective use of claims and payment systems to support operational performance, data integrity, and regulatory requirements, while partnering with IT on system enhancements and upgrades
• Possession of a Bachelor's degree from an accredited college or university with a major in business administration, finance, accounting, or a closely related field.
• Five (5) years of full-time or its equivalent experience as an administrator or manager in a health care organization, at least three (3) years of which must have been in either a patient financial services, patient business services, patient accounting, or insurance billing and collections.
• Certified Healthcare Financial Professional (CHFP) issued by the Healthcare Finance Management Association (HFMA)
• Certified Patient Account Manager (CPAM)
• Certified Clinic Account Manager (CCAM) certifications issued by the American Association of Healthcare Administrative Management (AAHAM)
• Certified Patient Account Technician (CPAT)
• Certified Clinic Account Technician (CCAT), combined with an additional four (4) years of qualifying experience, can be substituted for the required education.

Bayside Solutions, Inc. is not able to sponsor any candidates at this time. Additionally, candidates for this position must qualify as a W2 candidate. 

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