Director, Claims Administration

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Job Category:
Management/Executive

Department:
Claims Integrity

Location:

Los Angeles, CA, US, 90017

Position Type:
Full Time

Requisition

Salary Range: $ (Min.) - $ (Mid.) - $ (Max.)

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

The Director, Claims Administration, governs enterprise outcomes and risk controls, introducing a preventative orientation and regulatory accountability. This position is responsible for leading the end-to-end claims ecosystem, including claims adjudication, claims adjustments (escalations, disputes, general adjustments, and litigation-related requests), and strong focus on preventative controls through the Service Validation Unit (SVU). This role ensures timely, accurate, and complaint processing across all lines of business while strengthening upstream quality, embedding consistent control points, and reducing operational rework.

The Director has ownership of claims regulatory compliance and audit readiness. This position oversees daily production, inventory management, adjustment workflows, regulatory turnaround requirements, benefit and authorization interpretation, provide payment accuracy, and operational readiness for benefit, system, or regulatory changes. The role serves as an operational expert on managed care payment rules provider contracts, regulatory requirements, and claims operational dependencies.

The Director partners closely with cross functional teams to ensure end-to-end accuracy and operational integrity. This position fosters a culture of accountability, transparency, operational consistency, and continuous improvement.

This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Develops strategic plans, drives change and influences critical business outcomes.

Translates organizational expectations into disciplined operational execution by creating predictable workflows, establishing strong preventative control environments, and ensuring that claims processing is accurate, timely, and complaint. Strengthens upstream quality, improves consistency through standardized processes, ensures rigorous adherence to regulatory and contractual requirements, and supports an operational model that aims to remove rework, prevents defects, and supports high-performing administrative operations.

Through ownership of regulatory compliance and audit readiness perspective, provides strategic and operational leadership for all aspects of claims adjudication across all lines of business.

Monitors daily, weekly, and monthly production performance to ensure accuracy, timeliness, and regulatory compliance. Oversees examiner productivity models, workload balancing, Quality Assurance performance, and inventory trending to ensure strong operational predictability. Ensures benefit, authorization, eligibility, and provider data issues are resolved quickly and consistently, with emphasis on preventing repeat defects. Supports enterprise initiatives requiring claims operational expertise.

Leads all adjustment workflows, including escalations, provider disputes, general adjustments, and litigation-related claims review. Ensures all regulatory turnaround times (TATs) and provider/member notice requirements are consistently met, documented, and monitored. Serves and the operational escalation point for high-visibility or high-complexity claim issues, including those involving regulators, legal, provider groups, or executive leadership. Develops standardized…