Director, Claims Operations
SCAN Group, Long Beach, CA, United States
About SCAN
SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, a leading Medicare Advantage plan serving more than 300,000 members across several states. The organization is mission-driven, focusing on keeping seniors healthy and independent for over 40 years.
Job Overview As the Director of Claims Operations, you will direct the strategy and operation of the Claims Department to ensure claims are adjudicated efficiently, accurately, and in compliance with federal, state, and plan standards.
Responsibilities
Oversee and provide operational guidance to the claims mailroom, production, audit, provider disputes, delegated claim resolution, recovery, member balance billing, and compliance oversight functions.
Interpret benefits, delegated contracts, and provider contracts; analyze and resolve escalated and complex member and provider claims concerns.
Lead internal and external audit responses, develop corrective action plans, and prepare reports summarizing information and trends.
Attend committee meetings on regulatory requirements, compliance, member and provider issues, and strategic planning.
Study and apply federal and state regulations, legislation, and laws related to health insurance claims; develop and update internal policies and procedures.
Resolve non‑standard claims, negotiate settlements, and communicate with senior management regarding compliance and corrective actions.
Prepare an annual budget, approve expenditures, analyze variances, and implement corrective action plans to stay on budget.
Build and maintain strong teams of internal and external resources to resolve claim matters efficiently and accurately.
Set job expectations, monitor results, coach and counsel employees, enforce systems and policies, and maintain a safe work environment.
Plan and accomplish goals that drive efficient, accurate, and timely claims adjudication.
Maintain professional knowledge through educational workshops, publications, networking, and professional societies.
Seek innovators in AI to transform operations and member services.
Support the achievement of SCAN’s Vision and Goals.
Perform other duties as assigned.
Qualifications Bachelor’s degree or equivalent experience.
Preferred experience: 6 to 8 years in claims operations and/or systems with Medicare and Medicaid, including Medicare pricing rules, fee schedules, DRP, OPPS, bundling, and third‑party applications.
Knowledge of Medicare and Medicaid concepts, practices, and procedures.
Knowledge of HIPAA transaction sets, regulations, and privacy laws.
Demonstrated management experience.
Strong interpersonal skills, excellent written and oral communication, and a strong attention to detail.
Benefits
Base Pay Range: $147,900‑$214,030
Mostly Remote work mode
Annual employee bonus program
Robust wellness program
Generous paid time off (PTO)
11 paid holidays per year, one floating holiday, birthday off, and two volunteer days
Excellent 401(k) retirement saving plan with employer match
Robust employee recognition program
Tuition reimbursement
Opportunities to make a difference to members and community
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities SCAN is a proud Equal Employment Opportunity and affirmative action workplace. Employment decisions are made without regard to race, color, national origin, religion, age, sex (including pregnancy and related medical conditions), sexual orientation, gender identity, marital status, disability, protected veteran status, or any other status protected by law. A background check is required.
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Job Overview As the Director of Claims Operations, you will direct the strategy and operation of the Claims Department to ensure claims are adjudicated efficiently, accurately, and in compliance with federal, state, and plan standards.
Responsibilities
Oversee and provide operational guidance to the claims mailroom, production, audit, provider disputes, delegated claim resolution, recovery, member balance billing, and compliance oversight functions.
Interpret benefits, delegated contracts, and provider contracts; analyze and resolve escalated and complex member and provider claims concerns.
Lead internal and external audit responses, develop corrective action plans, and prepare reports summarizing information and trends.
Attend committee meetings on regulatory requirements, compliance, member and provider issues, and strategic planning.
Study and apply federal and state regulations, legislation, and laws related to health insurance claims; develop and update internal policies and procedures.
Resolve non‑standard claims, negotiate settlements, and communicate with senior management regarding compliance and corrective actions.
Prepare an annual budget, approve expenditures, analyze variances, and implement corrective action plans to stay on budget.
Build and maintain strong teams of internal and external resources to resolve claim matters efficiently and accurately.
Set job expectations, monitor results, coach and counsel employees, enforce systems and policies, and maintain a safe work environment.
Plan and accomplish goals that drive efficient, accurate, and timely claims adjudication.
Maintain professional knowledge through educational workshops, publications, networking, and professional societies.
Seek innovators in AI to transform operations and member services.
Support the achievement of SCAN’s Vision and Goals.
Perform other duties as assigned.
Qualifications Bachelor’s degree or equivalent experience.
Preferred experience: 6 to 8 years in claims operations and/or systems with Medicare and Medicaid, including Medicare pricing rules, fee schedules, DRP, OPPS, bundling, and third‑party applications.
Knowledge of Medicare and Medicaid concepts, practices, and procedures.
Knowledge of HIPAA transaction sets, regulations, and privacy laws.
Demonstrated management experience.
Strong interpersonal skills, excellent written and oral communication, and a strong attention to detail.
Benefits
Base Pay Range: $147,900‑$214,030
Mostly Remote work mode
Annual employee bonus program
Robust wellness program
Generous paid time off (PTO)
11 paid holidays per year, one floating holiday, birthday off, and two volunteer days
Excellent 401(k) retirement saving plan with employer match
Robust employee recognition program
Tuition reimbursement
Opportunities to make a difference to members and community
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities SCAN is a proud Equal Employment Opportunity and affirmative action workplace. Employment decisions are made without regard to race, color, national origin, religion, age, sex (including pregnancy and related medical conditions), sexual orientation, gender identity, marital status, disability, protected veteran status, or any other status protected by law. A background check is required.
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