Oversees the daily mechanics of claims production and ensures a controlled, disciplined, and highly reliable operational environment. Responsible for translating enterprise expectations into consistent frontline execution, maintaining a strong control environment, identifying emerging risks quickly, and building upstream partnerships that drive long-term operational maturity. Ensures claims operations are stable, predictable, and aligned to organizational goals.
Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities. Oversees day-to-day adjudication operations, ensuring a controlled, disciplined, and exceptionally reliable operational environment that is timely, accurate, and high-quality output by L.A. Care staff and external vendors, as necessary. Manages staff to consistently meet or exceed productivity, quality, and inventory performance targets.
Ensures all claims are processed within Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), Covered California and contractual turnaround requirements.
Establishes clear routing, triage, and prioritization models to balance workloads and avoid bottlenecks. Promotes operational discipline around standard operating procedures, configuration updates, and quality checkpoints.
Monitors daily, weekly, and monthly inventory at the claim, queue, and examiner level to anticipate risk and maintain a stable production environment.
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. Conducts structured production meetings with staff to review performance trends, quality indicators, and backlog prevention plans.
Identifies systemic constraints and drives timely mitigation through collaboration with cross-functional departments and stakeholders.
Oversees planning and execution during peak periods (open enrollment, benefit year-end/start, provider contract updates).
Partners with cross-functional departments to monitor and improve first-pass accuracy and aims to remove rework. Ensures examiners correctly apply benefits, coding, pricing, and provider contract terms.
Identifies claim types or provider groups with chronic accuracy issues and drives upstream corrections.
Manages initiatives to improve auto-adjudication rates through system corrections, routing refinement, and reduction of manual touchpoints. Ensures examiners receive timely, accurate updates on benefit changes, pricing methods, and new rules.
Acts as a critical operational partner to Configuration and Information Technology (I.T.) for system updates, benefit loads, provider contract implementations, and code-set changes. 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.
Participates in User Acceptance Testing (UAT) planning, test case development, operational validation, and go-live readiness for system changes affecting claims.
Identifies system behavior issues impacting adjudication and ensures prompt ticket creation, escalation, monitoring, and resolution.
