L.A. Care Health Plan · 8 hours ago
Senior Manager, Claims Administration
Los Angeles, CA
Full-time
Onsite
Senior Level
$118K/yr - $188K/yr
6+ years expL.A. Care Health Plan is the nation’s largest publicly operated health plan, providing health coverage to low-income Los Angeles County residents. The Senior Manager, Claims Administration is responsible for operational leadership in claims adjudication, ensuring accurate and compliant processing while managing a team to meet performance targets.
FitnessGovernmentHealth Care
Responsibilities
Oversees the daily mechanics of claims production and ensures a controlled, disciplined, and highly reliable operational environment
Responsible for translating enterprise expectations into consistent frontline execution, maintaining a strong control environment, identifying emerging risks quickly, and building upstream partnerships that drive long-term operational maturity
Ensures claims operations are stable, predictable, and aligned to organizational goals
Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities
Oversees day-to-day adjudication operations, ensuring a controlled, disciplined, and exceptionally reliable operational environment that is timely, accurate, and high-quality output by L.A. Care staff and external vendors, as necessary
Manages staff to consistently meet or exceed productivity, quality, and inventory performance targets
Ensures all claims are processed within Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), Covered California and contractual turnaround requirements
Establishes clear routing, triage, and prioritization models to balance workloads and avoid bottlenecks
Promotes operational discipline around standard operating procedures, configuration updates, and quality checkpoints
Monitors daily, weekly, and monthly inventory at the claim, queue, and examiner level to anticipate risk and maintain a stable production environment
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
Conducts structured production meetings with staff to review performance trends, quality indicators, and backlog prevention plans
Identifies systemic constraints and drives timely mitigation through collaboration with cross-functional departments and stakeholders
Oversees planning and execution during peak periods (open enrollment, benefit year-end/start, provider contract updates)
Partners with cross-functional departments to monitor and improve first-pass accuracy and aims to remove rework
Ensures examiners correctly apply benefits, coding, pricing, and provider contract terms
Identifies claim types or provider groups with chronic accuracy issues and drives upstream corrections
Manages initiatives to improve auto-adjudication rates through system corrections, routing refinement, and reduction of manual touchpoints
Ensures examiners receive timely, accurate updates on benefit changes, pricing methods, and new rules
Acts as a critical operational partner to Configuration and Information Technology (I.T.) for system updates, benefit loads, provider contract implementations, and code-set changes
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
Participates in User Acceptance Testing (UAT) planning, test case development, operational validation, and go-live readiness for system changes affecting claims
Identifies system behavior issues impacting adjudication and ensures prompt ticket creation, escalation, monitoring, and resolution
Ensures examiners receive clear, concise operational guidance tied to configuration updates and policy changes
Engages with Enrollment & Eligibility to resolve data discrepancies impacting member benefits or provider assignments
Partners with Provider Network on contract load timing, unclear terms, and pricing interpretation issues
Coordinates with Utilization Management on authorization-related adjudication issues and utilization policy questions
Collaborates with Payment Integrity to leverage findings that require upstream claims-processing adjustments
Aligns closely with the senior leadership to ensure seamless handoffs and minimal rework
Oversees creation and maintenance of daily production reports, dashboards, and forecasting tools
Uses data to analyze examiner performance, inventory patterns, quality trends, and root-cause drivers of errors
Uses analytical insights to develop operational plans that reduce cycle time, rework, and cost
Provides executive-level reporting on throughput, quality, aging, inventory at risk, and operational health
Ensures standard operating procedures (SOPs), desktop procedures, workflows, training materials, and job aids are current, accurate, and consistently used across the operation
Creates feedback loops with cross-functional departments to update procedures based on new rules or system changes
Ensures staff have clarity on benefit interpretation, contract logic, bundling/unbundling rules, and pricing methodologies
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, and 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, proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement
Perform other duties as assigned
Qualification
Required
Bachelor's Degree
At least 6 years of experience working in claims operations, 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 interpreting provider contracts, payment methodologies, and managed care benefit structures
Experience handling complex claim review, root-cause evaluation, adhering to regulatory TAT requirements, and ensuring accuracy
Experience working with Coordination of Benefits (COB) and Third-Party Liability (TPL) claims in a managed care setting
Experience leading teams, projects, initiatives, or cross-functional groups
Strong knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD)-10, DRG/ Ambulatory Payment Classification (APC), and pricing methodologies
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)
Exceptional written and verbal communication skills, including executive communication
Strong analytical and decision-making skills for complex claim scenarios
Ability to provide reporting requirements based on processes and/or regulatory requirements
Proven problem-solving 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 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
Preferred
Master's Degree in Business Administration or Related Field
Experience supporting regulatory audits, legal reviews, or corrective action plans
Benefits
Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)
Company
L.A. Care Health Plan
L.A. Care’s mission is to provide access to quality health care for L.A.
1001-5000 employees
H1B Sponsorship
L.A. Care Health Plan has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2024 (1)
2023 (1)
2021 (3)
2020 (1)
Funding
Current Stage
Late StageLeadership Team
Melanie Rainer
Chief Strategy and Transformation Officer
Recent News
MarketScreener
2025-08-27
2025-08-04
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