Central California Alliance for Health

Director

• Provides strategic management oversight in implementing, directing, and monitoring the Alliance’s Claims Department functions, including the development and implementation of new programs and services related to claims operations.
• Directs and oversees the Claims Department, acts as a subject matter expert, and provides direction and advice related to Claims Department functions and overall business operations.
• Directs, manages, and supervises Claims Department staff.

Claims Director

Consultant

• Designs and validates managed care payer models and performs moderately complex analysis to evaluate the feasibility of payer reimbursement methodologies
• Conducts moderately complex financial analysis to support successful payer reimbursement outcomes
• Coordinates and collaborates with internal and external stakeholders to achieve payer reimbursement objectives

Payer Analytics Consultant

Compliance

• Reporting to the Compliance Manager
• Conducts regular on-going review and analysis of relevant contractual provisions and state and federal statutes and regulations
• Researches questions from staff regarding regulatory compliance and responds to external requests for information, including related to DHCS, DMHC, and CMS requirements
• Assists with the implementation of internal and external audit processes to ensure compliance with federal and state statutes and regulations and provides related program guidance for all lines of business
• Coordinates Alliance delegate oversight activities to ensure subcontractors' compliance with state, federal, and Alliance requirements
• Performs other duties as assigned
• Interprets requirements, mitigates risk, and holds stakeholders accountable to protect member access to quality healthcare
• Performs internal audits and monitoring and handles/investigates internal concerns related to HIPAA, fraud, waste, and abuse

Claims Director

Payer Analytics Consultant

Compliance Specialist II