Assistant Director, Claim Operations
$95,000–$120,000 year
On-siteHuntington Beach, California, United States
Job Summary
Monitor daily claims operations including intake, adjudication, payment, reconciliation, aging inventory, and high-dollar claims while supporting the Claims Director. Track and resolve escalated issues involving providers, IPAs, vendors, and internal departments. Maintain claims dashboards, issue trackers, reconciliation reports, and audit documentation for leadership review. Ensure compliance with CMS, state, health plan, and internal requirements through accurate processes and audit-ready documentation. Assist with payment integrity reviews, pricing validation, coding accuracy, authorization linkage, and trend analysis. Coordinate with Provider Relations, Compliance, Finance, IT, and delegated entities to support timely issue resolution and operational alignment. Prepare claims data, reports, and status updates for internal reviews, external audits, and leadership meetings. Support claim-related projects, system implementations, testing, process improvements, and regulatory changes. Oversee all daily incoming, outgoing, and routing files while working closely with internal IT, the Delegation group, and vendors.
Required Qualifications
- Minimum 3+ years of experience in health plan, managed care, Medicare Advantage, IPA, TPA, or claims operations environment
- Working knowledge of claims intake, adjudication, pricing, payment, reconciliation, denials, pending, and provider dispute workflows
- Experience using claims systems and reporting tools
- Proficiency with Microsoft Excel, Outlook, Word, and Teams
- Strong organizational, analytical, communication, and follow-up skills with the ability to manage multiple priorities and confidential information
- Reliably commute or plan to relocate before starting work
- Must occasionally lift and/or move up to 25-50 pounds
Desired Qualifications
- Bachelor's degree in business, healthcare administration, finance, public health, or a related field preferred; equivalent claims operations experience may be considered
- Familiarity with CMS, state, health plan, and delegated entity requirements related to claims administration is preferred
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