California Licensed Claims Director

Job Summary

Leading the strategic and operational aspects of claims administration, the full-time California Licensed Claims Director will ensure accurate, timely, and compliant adjudication and payment of medical, behavioral health, pharmacy, and ancillary claims while working remotely.

Key responsibilities

• Direct all aspects of claims intake, adjudication, payment, adjustment, and provider reimbursement activities
• Establish and monitor operational metrics, SLAs, productivity standards, and quality indicators to ensure compliance with regulatory requirements
• Lead continuous improvement initiatives focused on automation, efficiency, payment accuracy, and provider experience

Required qualifications

• Bachelor's degree in Business Administration, Healthcare Administration, Finance, Public Health, or related field, or equivalent experience
• Minimum 9 years of progressive healthcare claims operations experience
• Minimum 5 years of leadership experience managing managers and/or large operational teams
• Experience within Medicare Advantage, Medicaid, Managed Care, Health Plan, or Payer environments