Manager, Claims Quality Assurance
L.A. Care Health Plan
full-time
Posted on:
Location Type: Office
Location: Los Angeles • California • United States
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Salary
💰 $102,183 - $163,492 per year
About the role
- Managing and leading the operational quality program focused on preventative and predictive orientation that evaluates and strengthens accuracy across the entire claims lifecycle
- Ensuring L.A. Care’s Core Administrative Operations maintain high processing accuracy, strong control points, and consistent application of benefits, provider contracts, coding standards, and regulatory requirements
- Overseeing operational QA testing, examiner-level audit programs, quality scoring, root-cause identification, and corrective action validation
- Supporting regulatory readiness through mock audit participation, audit universe/sample creation, and quality documentation preparation
- Managing staff and partnering closely with cross functional key stakeholders to drive upstream improvements
- Monitoring and validating adjustment processing, provider disputes resolutions, and post-payment quality outcomes tied to Payment Integrity remediation.
Requirements
- Bachelor's Degree
- At least 5 years of experience claims operations, claims auditing, claims QA, or complex claims operational functions
- At least 3 years of experience leading, supervising /managing staff
- Experience leading teams, projects, initiatives, or cross-functional groups
- Experience in Medicaid, Medicare, and Commercial managed care lines of business
- Hands-on experience conducting claims testing or accuracy audits
- Deep experience interpreting provider contracts, payment methodologies, and managed care benefit structures
- Demonstrated experience with high complexity claims review and RCA
- Experience supporting or preparing for regulatory audits (DMHC, DHCS, CMS)
- Demonstrated experience analyzing claims defects and validating corrective actions.
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 operationsclaims auditingclaims QAclaims testingaccuracy auditsroot-cause analysisregulatory auditsprovider contracts interpretationpayment methodologiesmanaged care benefit structures
Soft skills
leadershipstaff managementcross-functional collaborationproject managementanalytical skills
Certifications
Bachelor's Degree