Claims Operations Manager

We believe every candidate deserves thoughtful consideration. That’s why we do not use AI or automated systems to review applications. Every application is reviewed by a real human member of our team. Because we take the time to give each submission the attention it deserves, our review process may take a little longer — and we genuinely appreciate your patience as we work through applications carefully and respectfully. 

While we encourage all interested applicants to apply, we do give priority to those who live in, or near, our service counties: Santa Cruz, Monterey, Merced, San Benito, and Mariposa. Our mission of accessible, quality health care guided by local innovation leads everything we do, and having team members who are connected to the communities we serve strengthens our ability to deliver on that commitment. 

We have an opportunity to join the Alliance as the Claims Operations Manager leading the Claims Operations Unit within the Claims Department. 

This position can be located in one of our service counties (Mariposa, Merced, Monterey, Santa Cruz, or San Benito) or remotely in California with expected travel to Alliance service area(s) once a quarter. Must reside in California upon hire.

Reporting to the Claims Director, this position: 

• Manages and leads the Claims Operations Unit, acts as a subject matter expert, and provides guidance on claims operations functions and departmental operations
• Provides management oversight related to planning, leading, and implementing claims operations activities, including audits, root-cause analysis, quality reporting, compliance coordination, and governance of claims policies and procedures
• Oversees the full Provider Dispute Resolution (PDR) lifecycle to ensure accurate, timely, and compliant dispute resolution
• Manages, supervises, mentors, and trains assigned staff

We support the health of our provider relationships. Our teams work closely together to support Alliance members' access to care by ensuring medical services are paid to network providers accurately and on time.

• Strong understanding of end-to-end claims and PDR operations (volume, accuracy, turnaround)
• Uses data and tools to spot trends, make decisions, and actively identify opportunities for automation
• Solid experience with Medi-Cal and Medicare, with compliance built into how they work
• Focuses on fixing root causes instead of quick fixes
• Builds, engages, and supports teams through coaching, accountability, and clear expectations
• Brings new ideas, challenges the way things are done, and works closely with other teams to drive better outcomes

To read the full position description and list of requirements, click here. 

• Knowledge of:
• Claims processing functions, including data entry, adjudication, and PDR workflows
• Medi‑Cal, Medicare, and related regulatory requirements that impact claims processing and dispute resolution
• Operational improvement activities, workflow design, and inventory management within a managed care environment
• Medical terminology, billing practices, and coding standards relevant to claims adjudication
• Audit processes, quality standards, and compliance requirements, related to claims operations and dispute workflows 
• Research, analysis and reporting methods
• Ability to:
  • Train, mentor, supervise, and evaluate the work of staff, promote an atmosphere of teamwork and cooperation, and motivate staff to achieve goals and objectives 
  • Develop work plans and workflows and organize and prioritize unit activities to meet performance metrics
  • Organize and prioritize the work of others, delegate effectively, and follow up on work assignments
  • Interpret, apply and explain complex principles, policies, regulations, terms and procedures related to area of assignment
  • interpret operational data, identify trends, and apply insights, collaborate with Claims Quality on PDR analytics, and identify opportunities for increased auto‑adjudication
• Education and Experience:
  • Bachelor’s degree in Business, Healthcare Administration, Public Health, or a related field
  • A minimum of six years of experience in a healthcare or managed care environment which included a minimum of three years of supervisory or management experience in Medi-Cal and Medicare claims operations (a Master’s degree may substitute for two years of the general healthcare or managed care experience); or an equivalent combination of education and experience may be qualifying

• We are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams.
• While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected.
• In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.

We are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us. 

Join us at Central California Alliance for Health (the Alliance), where you will be part of a culture that is respectful, diverse, professional and fun, and where you are empowered to do your best work. As a regional non-profit health plan, we serve members in Mariposa, Merced, Monterey, San Benito and Santa Cruz counties. To learn more about us, take a look at our Fact Sheet.

The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender perception or identity, national origin, age, marital status, protected veteran status, or disability status. We are an E-Verify participating employer

At this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship.