Claims Operations Manager

We have an opportunity to join the Alliance as the Claims Operations Manager leading the Claims Operations Unit within the Claims Department.

This position can be located in one of our service counties (Mariposa, Merced, Monterey, Santa Cruz, or San Benito) or remotely in California with expected travel to Alliance service area(s) once a quarter. Must reside in California upon hire.

WHAT YOU'LL BE RESPONSIBLE FOR

Reporting to the Claims Director, this position:

• Manages and leads the Claims Operations Unit, acts as a subject matter expert, and provides guidance on claims operations functions and departmental operations
• Provides management oversight related to planning, leading, and implementing claims operations activities, including audits, root-cause analysis, quality reporting, compliance coordination, and governance of claims policies and procedures
• Oversees the full Provider Dispute Resolution (PDR) lifecycle to ensure accurate, timely, and compliant dispute resolution
• Manages, supervises, mentors, and trains assigned staff

ABOUT THE TEAM

We support the health of our provider relationships. Our teams work closely together to support Alliance members' access to care by ensuring medical services are paid to network providers accurately and on time.

THE IDEAL CANDIDATE

• Strong understanding of end-to-end claims and PDR operations (volume, accuracy, turnaround)
• Uses data and tools to spot trends, make decisions, and actively identify opportunities for automation
• Solid experience with Medi-Cal and Medicare, with compliance built into how they work
• Focuses on fixing root causes instead of quick fixes
• Builds, engages, and supports teams through coaching, accountability, and clear expectations
• Brings new ideas, challenges the way things are done, and works closely with other teams to drive better outcomes

WHAT YOU'LL NEED TO BE SUCCESSFUL

To read the full position description and list of requirements, click here.

• Knowledge of:
• • Claims processing functions, including data entry, adjudication, and PDR workflows
  • Medi‑Cal, Medicare, and related regulatory requirements that impact claims processing and dispute resolution
  • Operational improvement activities, workflow design, and inventory management within a managed care environment
  • Medical terminology, billing practices, and coding standards relevant to claims adjudication
  • Audit processes, quality standards, and compliance requirements, related to claims operations and dispute workflows
  • Research, analysis and reporting methods
• Ability to:
  • Train, mentor, supervise, and evaluate the work of staff, promote an atmosphere of teamwork and cooperation, and motivate staff to achieve goals and objectives
  • Develop work plans and workflows and organize and prioritize unit activities to meet performance metrics
  • Organize and prioritize the work of others, delegate effectively, and follow up on work assignments
  • Interpret, apply and explain complex principles, policies, regulations, terms and procedures related to area of assignment
  • interpret operational data, identify trends, and apply insights, collaborate with Claims Quality on PDR analytics, and identify opportunities for increased auto‑adjudication
• Education and Experience:
  • Bachelor's degree in Business, Healthcare Administration, Public Health, or a related field
  • A minimum of six years of experience in a healthcare or managed care environment which included a minimum of three years of supervisory or management experience in Medi-Cal and Medicare claims operations (a Master's degree may substitute for two years of the general healthcare or managed care experience); or an equivalent combination of education and experience may be qualifying

OTHER INFORMATION

• We are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams.
• While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected.
• In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.

COMPENSATION INFORMATION

• Zone 1 Pay Range: $118,000 - $148,000
  Typical areas in Zone 1: Santa Cruz, San Benito, and Monterey Counties, Bay Area, Sacramento, Los Angeles and San Diego areas
  
• Zone 2 Pay Range: $110,000 - $140,000
  Typical areas in Zone 2: Mariposa and Merced Counties, Fresno area, Bakersfield, Eastern California, San Luis Obispo area, and the Central Valley (except Sacramento)

The applicable salary ranges are based on work location and are aligned to a zone according to the cost of labor in your area. All ranges are subject to change in the future. We are happy to provide the full compensation range for the role, answer any questions that you have, or share the applicable pay zone for your location if it's not one of the typical areas listed. You can reach out to careers@thealliance.health, and a member from our Talent Acquisition team will be in touch.

The hiring ranges represent a good‑faith estimate of what we expect to pay for this role upon hire and are not the full compensation ranges. Employees typically have opportunities for growth within the full compensation range over time based on performance and merit. Final compensation will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferable experience related to the position, education, or training), as well as other factors (internal equity, market factors, and geographic location).