Director – Claims
Astrana Health
full-time
Posted on:
Location Type: Hybrid
Location: Monterey Park • California • United States
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Salary
💰 $134,649 - $167,800 per year
Job Level
About the role
- Provide strategic direction for the claims department, aligning operations with company goals and regulatory requirements
- Lead, mentor, and develop a high-performing claims management team
- Collaborate with executive leadership to establish and achieve claims-related KPIs and financial targets
- Identify the root cause of any operational weaknesses and implement the best solution
- Serve as a thought partner to internal and external stakeholders to achieve mutual goals
- Oversee end-to-end claims operations, claims processing, adjudication, and resolution to ensure timeliness, accuracy, and compliance
- Develop, implement, review dashboards, reports, policies, procedures, and workflows to optimize efficiency and mitigate errors
- Team accountability for areas such as – timeliness reporting to the health plans, encounter reports, weekly inventory and workflow reports, and IPA claims summary report for board meetings
- Monitor and address claim denial trends, providing actionable insights and corrective strategies
- Manage relationships with payers, third-party administrators, and other key stakeholders
- Ensure compliance with state, federal, and industry regulations, including HIPAA and CMS guidelines
- Prepare and present regular reports on claims performance, trends, and department metrics
- Conduct audits and reviews to maintain high standards of accuracy and compliance
Requirements
- Bachelor’s degree in healthcare administration, business, or a related field
- 8+ years of progressive responsibility, preferably in a managed care setting
- Knowledge of DMHC, DHS, and CMS regulations and guidelines
- Proficient in knowledge of CPT, HCPCS, ICD-10
- Strong knowledge of MSO operations, healthcare reimbursement models, and payer/provider dynamics
- Expertise in claims processing systems and technologies (e.g., EHR, claims adjudication software)
- In-depth understanding of healthcare regulations, including HIPAA and CMS guidelines
- Prior experience working in managed care/IPA setting
- You're great for the role if:
- You have a master's degree
- Have EZ-CAP software experience
Benefits
- Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Dr., Monterey Park, CA 91754.
- Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at **humanresourcesdept@astranahealth.com** to request an accommodation.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
claims processingadjudicationCPTHCPCSICD-10claims processing systemshealthcare reimbursement modelsMSO operationsdata analysisreporting
Soft Skills
leadershipmentoringcollaborationstrategic directionproblem-solvingcommunicationaccountabilityinsight generationrelationship managementpresentation skills
Certifications
Bachelor's degreeMaster's degree