Manager, Claims Compliance
L.A. Care Health Plan
full-time
Posted on:
Location Type: Office
Location: Los Angeles • California • United States
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Salary
💰 $117,509 - $188,015 per year
About the role
- Ensures that Core Administrative Operations has a strong and sustainable compliance foundation.
- Interprets regulatory guidance, identifies compliance risks, develops training that operationalizes regulatory changes, and builds documentation that ensures accuracy and audit readiness.
- Strengthens operational integrity, improves adherence to state/federal requirements, and equips staff with the knowledge and tools needed to process claims accurately and consistently.
- Monitors compliance with regulatory agencies, NCQA, and contractual requirements related to claims processing, adjustments, disputes, configuration, and payment accuracy.
- Oversees compliance monitoring and internal validation activities to ensure critical regulations are consistently met.
- Serves as subject-matter expert on regulatory and contractual requirements affecting claims and related administrative functions.
- Designs, implements, and oversees comprehensive operational training programs across cross functional teams.
- Partners with operational leaders and QA to ensure procedures align with audit findings, corrective actions, and quality standards.
Requirements
- At least 6 years of experience in claims compliance, regulatory oversight, or related experience in a managed care environment.
- At least 4 years of experience leading, supervising/managing staff.
- Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.
- Experience leading teams, projects, initiatives, or cross-functional groups.
- Experience with claims processing, adjustments, payment methods, and associated core administrative operations.
- Experience in Medicaid, Medicare, and Commercial managed care lines of business.
- Experience developing training programs or documentation for claims or other administrative operations.
- Deep experience interpreting regulations, provider contracts, payment methodologies, and managed care benefit structures.
- Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing.
- Experience supporting or preparing for regulatory audits (Department of Managed Health Care (DMHC), California Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS)) including corrective action planning.
Benefits
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
claims complianceregulatory oversightclaims processingpayment methodstraining program developmentdocumentationregulatory auditscorrective action planninginterpretation of regulationsprovider contracts
Soft skills
leadershipsupervisioncross-functional collaborationoperational integritycommunicationtrainingproblem-solvingorganizational skillsattention to detailaudit readiness
Certifications
L.A. Care Management Certificate Training Program