Director - Claims
Astrana Health, Monterey Park, CA, United States
Location:
1600 Corporate Center Dr., Monterey Park, CA 91754
Compensation:
$134,650 - $167,801 / year
Department:
Ops - Claims Ops
Description The Director - Claims will be responsible for overseeing the end-to-end claims management process, ensuring accuracy, efficiency, and compliance with regulatory standards. This role involves leading a team of claims professionals, optimizing workflows, and driving strategic initiatives to improve claims operations. The ideal candidate is an experienced leader with a deep understanding of healthcare claims, payer-provider relationships, and a commitment to delivering exceptional service.
What You'll Do Leadership & Strategy
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.
Claims Management Operations
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.
Compliance & Reporting
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.
Qualifications
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 knowledge of CPT, HCPCS, ICD-10, and 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.
You have EZ-CAP software experience.
Environmental Job Requirements and Working Conditions
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.
The national target pay range for this role is $134,649.87 - $167,800.67. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.
Astrana Health is proud to be an Equal Employment Opportunity and Affiirmative Action employer. We do not discriminate based on 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.
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
#J-18808-Ljbffr
1600 Corporate Center Dr., Monterey Park, CA 91754
Compensation:
$134,650 - $167,801 / year
Department:
Ops - Claims Ops
Description The Director - Claims will be responsible for overseeing the end-to-end claims management process, ensuring accuracy, efficiency, and compliance with regulatory standards. This role involves leading a team of claims professionals, optimizing workflows, and driving strategic initiatives to improve claims operations. The ideal candidate is an experienced leader with a deep understanding of healthcare claims, payer-provider relationships, and a commitment to delivering exceptional service.
What You'll Do Leadership & Strategy
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.
Claims Management Operations
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.
Compliance & Reporting
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.
Qualifications
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 knowledge of CPT, HCPCS, ICD-10, and 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.
You have EZ-CAP software experience.
Environmental Job Requirements and Working Conditions
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.
The national target pay range for this role is $134,649.87 - $167,800.67. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.
Astrana Health is proud to be an Equal Employment Opportunity and Affiirmative Action employer. We do not discriminate based on 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.
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
#J-18808-Ljbffr