Senior Manager, Claims Adjustments

Job Summary

The Senior Manager, Claims Adjustments manages all adjustment-related operational workflows, including provider disputes, escalated claim reviews, complex adjustments, and litigation-related claim support. This position ensures that adjustment decisions are accurate, timely, consistent, and fully compliant with state, federal, and contractual requirements. The position functions as the operational leader for all claim adjustments that exceed routine examiner responsibilities and require higher-level investigation or coordination.

The Senior Manager leads a team of adjustment analysts and dispute specialists, building a culture of accuracy, documentation discipline, transparency, and initiative-taking issue identification.

The Senior Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.

Duties

Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities. Manages daily operations for all non-routine claim adjustments, including escalated cases, complex pricing reviews, and benefit or authorization-related adjustments. Ensures that adjustments are accurate, compliant, and completed within regulatory and contractual timeframes.

Oversees consistent application of payment rules, contract terms, and standardized work instructions. Builds and maintains clear adjustment pathways based on claim type, complexity, and regulatory requirements.

Oversees provider disputes requiring adjustment, including root-cause analysis and documentation of findings.

Ensures all provider adjustments meet Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), and contractual (TAT) requirements.

Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/ or executive management to define, prioritize, and develop projects and programs. Provides operational support for high-profile or complex provider inquiries involving reimbursement, coding, contract terms, or medical policy.

Manages communication with cross-functional departments and/or teams when needed. Ensures all adjustments are documented accurately and consistently, supporting audit readiness.

Partners with Compliance to validate adherence to regulatory standards and internal policies. Escalates potential compliance gaps or systemic issues that may require corrective action.

Partners with Legal to support claim-level discovery, case review, and preparation of adjustment packages.

Duties Continued

Provides operational insight on benefit application, contract interpretation, and pricing methodology relevant to legal inquiries. Ensures adjustments completed in relation to litigation or legal review are precise and audit ready.

Collaborates closely with cross-functional departments to resolve adjustment-related dependencies. Communicates root-cause drivers of adjustment volume and advocates for upstream corrections. Ensures adjustment processes are aligned with enterprise standards and system logic.

Develops reports and dashboards tracking adjustment volume, turnaround performance, accuracy trends, and systemic issues. Identifies trends in adjustment drivers and collaborates on upstream solutions that reduce rework.

Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions

Provides executive summaries for high-risk or high-complexity adjustment issues.

Manages staff and the day-to-day activities in the department. Participates in the department budgeting process. Responsible for scheduling, training, performance, corrective actions, mentoring, developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team. Responsible for overseeing and managing the budgets of their respective departments.

Builds a culture of rigor, transparency, analytical curiosity, initiative-taking issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.

Perform other duties as assigned.

Education Required

Bachelor's Degree

In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Master's Degree in Business Administration or Related Field

Experience

At least 6 years of experience working in claims, provider disputes, adjustments, or related operational functions.

At least 5 years of experience in leading, supervising and/or managing staff

Experience in Medicaid, Medicare, and Commercial managed care lines of business.

Experience in interpreting provider contracts, payment methodologies, and managed care benefit structures.

Experience managing complex claim review, root-cause evaluation, adhering to regulatory TAT requirements, and ensuring accuracy.

Experience leading teams, projects, initiatives, or cross-functional groups

Experience supporting regulatory audits, legal reviews, or corrective action plans.

Skills

Strong understanding of adjudication, coding, pricing, the application of Division of Financial Responsibility (DOFR) to claims processing, and managed care payment rules.

An advanced knowledge of contractual pricing mechanisms for inpatient, outpatient, Long Term Care (LTC) and ancillary services.

Knowledge of relevant regulatory requirements (DMHC, DHCS, CMS).

Strong analytical and decision-making skills for complex claim scenarios.

Ability to provide reporting requirements based on processes and/or regulatory requirements

Proven critical thinking skills and ability to translate knowledge to the department

Strong people skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.

Strong attention to detail and ability to manage multiple priorities and tight deadlines.

Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.

Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.

Must have a deep understanding of financial principles.

Ability and exceptional knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.

Demonstrated ability to make informed decisions.

Strong verbal, written communication, and presentation skills, including executive communication.

Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.

Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

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Additional Information