Claims Director

Contra Costa County; Martinez (CA); On-site; USD 170,000 - 230,000; Full time

Job summary

Contra Costa Health Plan seeks a Health Plan Division Director – Exempt (Claims Director) to lead its claims operations with a focus on accuracy, compliance, and timely payments across Medi-Cal, Medicare, and commercial lines.

You will work with executive leadership to set strategic direction, oversee adjudication, payment integrity, and vendor relationships, and drive continuous improvement in a large public health plan.

Qualifications

• Possession of a master’s degree in a related field or higher is required.
• Experience leading health plan claims operations with regulatory oversight is essential.
• Strong leadership, communication, and vendor management skills are expected.

Responsibilities

• Provide leadership and oversight of all CCHP claims operations including adjudication, adjustments, payment integrity, and recovery activities.
• Direct, coach, and evaluate managers and supervisors responsible for daily claims operations.
• Oversee clearinghouses and other claims-related vendors and monitor contract performance and issue resolution.
• Direct the use and optimization of Epic Tapestry for claims adjudication, payment rules, edits, and reporting; ensure changes are tested and implemented.
• Ensure full compliance with federal, state, and local regulations (DHCS, DMHC, CMS).
• Establish and monitor KPIs related to timeliness, accuracy, financial controls, and regulatory compliance.
• Serve as primary liaison for claims-related matters with providers, county partners, auditors, and regulatory agencies.
• Identify operational risks and corrective actions; report to executive leadership.

Skills

Managed Care Leadership

Medicaid & Medicare knowledge

Strategic Thinker

Strong Communicator

Solution-Oriented

Professional & Collaborative

Discreet & Judicious

Education

Master’s degree in Business Administration / Health Care Administration / Public Administration / Public Health

Bachelor’s degree + 2 years qualifying experience substitution

Job description

Why Join the Contra Costa Health Plan (CCHP)?

Contra Costa Health is offering an excellent opportunity for a Health Plan Division Director – Exempt (Claims Director) within Contra Costa Health Plan (CCHP). This role plays a key leadership function within CCHP, providing strategic and operational oversight of the claims function to ensure accurate, timely, and compliant payment of healthcare services. It is responsible for setting directions, establishing controls, and guiding continuous improvement across claims operations while supporting positive provider relationships, regulatory compliance, and the financial integrity of the health plan.

The position works closely with executive leadership and cross-functional partners to align claims operations, with accountability for claims adjudication, payment integrity, regulatory compliance, and vendor oversight across Medi-Cal, Medicare, and commercial lines of business. This role ensures claims operations support member access, provider relationships, and the financial integrity of the health plan.

About Contra Costa Health Plan:

CCHP is a federally qualified, state-licensed, county-sponsored Health Maintenance Organization serving more than 250,000 residents of Contra Costa County. As part of Contra Costa Health, the County’s integrated public health system, the health plan plays a central role in delivering accessible, high-quality care to a diverse population. CCHP’s primary business line is Medi-Cal but also has a growing D-SNP product line as well as Commercial lines of business.

We are looking for someone who is:

• Experienced in Managed Care Leadership: Brings extensive experience leading health plan claims operations within a managed care environment, including responsibility for complex, high-volume systems
• Knowledgeable in Medicaid and Medicare: Demonstrates deep understanding of program requirements, claims payment policy, audits, and regulatory oversight
• A Strategic Thinker: Able to translate regulatory requirements and organizational priorities into sustainable operational strategies
• A Strong Communicator: Clearly conveys complex claims, financial, and compliance issues to executive leadership, staff, providers, and external partners
• Solution-Oriented: Proactively identifies operational risks and implements improvements that enhance accuracy, timeliness, and provider experience
• Professional and Collaborative: Builds strong relationships across finance, compliance, IT, utilization management, and external vendors
• Discreet and Judicious: Exercises sound judgment when managing confidential, sensitive, and high-risk matters

What you will typically be responsible for:

• Providing leadership and oversight of all CCHP claims operations, including claims adjudication, adjustments, payment integrity, and recovery activities
• Directing, coaching, and evaluating managers and supervisors responsible for daily claims operations
• Overseeing clearinghouses and other claims-related vendors, including contract performance and issue resolution
• Directing the use and optimization of Epic Tapestry for claims adjudication, payment rules, edits, and reporting, and ensuring system changes are appropriately tested, documented, and implemented
• Ensuring full compliance with federal, state, and local regulations, including DHCS, DMHC, and CMS requirements
• Establishing and monitoring key performance indicators related to claims timeliness, accuracy, financial controls, and regulatory compliance
• Serving as the primary liaison for claims-related matters with providers, county partners, auditors, and regulatory agencies
• Identifying operational risks, audit findings, and systemic issues, and ensuring timely corrective action and reporting to executive leadership

A few reasons you might love this job:

• You will shape the strategic direction of claims operations for a large, mission-driven public health plan
• You will have a direct impact on provider payment accuracy, regulatory compliance, and financial stewardship
• You will work with experienced, dedicated professionals committed to equity, accountability, and operational excellence
• You will play a key role in supporting healthcare access for Contra Costa County’s most vulnerable populations

A few challenges you might face in this job:

• Navigating frequent changes in Medi-Cal, Medicare, and managed care claims regulations
• Balancing regulatory compliance, financial controls, and provider experience in a complex environment
• Managing system limitations, data dependencies, and cross-functional coordination
• Leading large-scale operational improvements while maintaining day-to-day performance

Competencies Required:

• Delegating - Ability to inspire and create new leaders by developmental opportunities
• Coaching and Developing Others - Ability to mentor and have staff grow professionally
• Managing Performance - Leader in finding creative ways to recognize staff in a governmental environment
• Visionary Leadership - Influence a team to believe in working in a high performing environment and not accept the bureaucratic myth – or a mentality for doing minimum work
• Teamwork - Collaborating with others is critical in this role
• Leading Cross-Divisional Collaboration - Patient and empathetic leaders will be successful in understanding the sensitivities of clinical teams
• Managing and Facilitating Change - Commitment to be being a Change Agent due to the heavy demands on policies with governmental programs
• Professional Impact - May be called upon to be a Public Relations guru in helping the CEO with external issues in the community and the Safety Net providers
• Fact Finding - Research and obtain reliable data and facts for projects

Education:

Possession of a master’s degree from an accredited college or university with a major in Business Administration, Health Care Administration, Public Administration, Public Health, or a closely related field.

Experience:

Five (5) years of progressively responsible professional experience in health care administration, health plan operations, or a closely related field, including at least two (2) years in a management or supervisory capacity.

Substitution for Education:

Possession of a Bachelor’s degree from an accredited college or university and two (2) additional years of qualifying experience may be substituted for the Master’s degree. Two (2) additional years of qualifying experience may be substituted for academic major concentration.

Desirable Qualifications:

• Delivering Results: Achieves organizational and regulatory goals through strong operational leadership and accountability
• Legal & Regulatory Navigation: Interprets and applies complex laws, regulations, and guidance
• Ownership & Accountability: Takes responsibility for outcomes and ensuring follow-through across teams
• Technology Leadership: Guides the effective use of claims and payment systems to support operational performance, data integrity, and regulatory requirements, while partnering with IT on system enhancements and upgrades
• Oral Communication: Effectively communicates complex information to executive and external audiences

This position is exempt from the merit system and will not follow regular County recruitment and selection procedures. Only the most qualified candidates will be invited to interview.

CONVICTION HISTORY

After you receive a conditional job offer, you will be fingerprinted, and your fingerprints will be sent to the California Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI). The resulting report of your conviction history (if any) will be used to determine whether the nature of your conviction conflicts with the specific duties and responsibilities of the job for which you have received a conditional job offer. If a conflict exists, you will be asked to present any evidence of rehabilitation that may mitigate the conflict, except when federal or state regulations bar employment in specific circumstances. Having a conviction history does not automatically preclude you from a job with Contra Costa County. If you accept a conditional job offer, the Human Resources department will contact you to schedule a fingerprinting appointment.

DISASTER SERVICE WORKER

All Contra Costa County employees are designated Disaster Service Workers through state and local law. Employment with the County requires the affirmation of a loyalty oath to this effect. Employees are required to complete all Disaster Service Worker-related training as assigned, and to return to work as ordered in the event of an emergency.

EQUAL EMPLOYMENT OPPORTUNITY

It is the policy of Contra Costa County to consider all applicants for employment without regard to race, color, religion, sex, national origin, ethnicity, age, disability, sexual orientation, gender, gender identity, gender expression, marital status, ancestry, medical condition, genetic information, military or veteran status, or other protected category under the law.