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L.A. Care Health Plan · 15 hours ago

Manager, Claims Research and Remediation

Los Angeles, CA

Full-time

Onsite

Senior Level

$102K/yr - $163K/yr

5+ years exp

L.A. Care Health Plan is the nation’s largest publicly operated health plan, dedicated to providing health coverage to low-income residents of Los Angeles County. The Manager, Claims Research and Remediation oversees a specialized team focused on investigating and resolving complex claims issues, ensuring accuracy and compliance while coordinating with various stakeholders.

FitnessGovernmentHealth Care

Responsibilities

Drives L.A. Care’s most critical investigative and corrective work

Deals with the highest regulatory, financial, or legal exposure

Ensures that investigations are comprehensive, evidence-based, and defensible, and that remediation actions are accurate, auditable, and sustainable

Leveraging analytics, structured project leadership, and strong cross-functional collaboration, protects the organization while strengthening upstream processes and long-term operational reliability

Leads the investigation of complex issues involving benefit configuration errors, contract misinterpretation, pricing defects, authorization discrepancies, coding anomalies, or systemic system defects

Reconstructs claims outcomes across multiple adjudication cycles, benefit periods, and contract iterations to determine root cause and impact

Conducts multi-layered RCA involving claims rules, configuration tables, provider contracts, Electronic Data Interchange (EDI) inputs, pricing logic, benefit grids, Utilization Management (UM) decisions, and historical system changes

Develops complete audit trails documenting 'what happened,' 'why it happened,' and 'how to prevent recurrence.'

Partners with Legal to support litigation research, discovery preparation, and exposure modeling

Conducts claims sampling, case reconstruction, data pulls, validation, and preparation of evidentiary claim packages

Provides operational insights and documentation required for regulators, external auditors, and legal proceedings

Works with Compliance to design corrective action plans and support enterprise readiness during regulatory reviews, inquiries, or settlements

Partners with Claims Administration and Quality Assurance (QA) in the development of end-to-end remediation plans, including identification, retrieval, correction, reprocessing, and reconciliation of affected claims

Oversees multi-layered remediation for retroactive benefit changes, contract corrections, reimbursement updates, or operational/system defects

Ensures remediation execution is compliant, accurate, documented, and coordinated with cross-functional key stakeholders

Recommends QA/validation protocols before, during, and after remediation cycles

Develops models to quantify regulatory, legal, or financial exposure across multiple scenarios

Validates datasets received from other business units and ensures completeness, accuracy, and audit-readiness

Performs scenario testing to predict downstream implications of proposed changes, settlements, or corrective actions

Partners with Finance on financial projections and reserve-setting guidance

Works closely with cross-functional key stakeholders to validate findings and ensure remediation is accurate and aligned with operational rules

Identifies upstream gaps uncovered during investigations and partners with business owners to implement preventive controls

Provides recommendations for system enhancements, procedural changes, or policy updates to reduce recurrence of similar issues

Creates executive-level reports summarizing findings, root causes, risks, and recommended actions

Produces audit-ready documentation for regulators, legal stakeholders, Compliance, and leadership

Maintains strict confidentiality, secure data handling protocols, and precise audit trails

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

Assigns work, monitors progress, ensures quality, and maintains strong project management discipline

Builds a culture grounded in analytical precision, data integrity, critical thinking, and investigative rigor and supports proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement

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

Performs other duties as assigned

Qualification

Claims ResearchRoot Cause AnalysisData AnalysisRegulatory KnowledgeLeadershipSQLExcelCommunication SkillsInterpersonal SkillsConflict Resolution

Required

Bachelor's Degree

At least 5 years of experience working in claims research, auditing, payment integrity, provider disputes, adjustments, or complex claims operational functions

At least 3 years of leading, supervising /managing staff

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

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

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

Demonstrated experience with high complexity claims review and RCA

Experience interacting with Legal, Compliance, or regulators

Strong experience with claims system logic, configuration dependencies, provider contracts, and benefit structures

Expert-level analytical and investigatory skills

Ability to analyze complex datasets and reconcile conflicting data sources

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

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

Strong understanding of pricing methodologies, coding rules, benefit logic, and contract interpretation

Deep knowledge of relevant regulatory requirements (Department of Managed Health Care (DMHC), California Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS))

High proficiency with Excel, SQL, Access, or claims-data tools

Ability to lead cross-functional, high-pressure, confidential initiatives with minimal oversight

Demonstrated ability to make informed decisions

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

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

Certified Professional Coder (CPC) or other equivalent Coding Certification