Claims Manager

LaSalle Medical Associates IPA; San Bernardino (CA); On-site; USD 87,000 - 98,000; Full time

Job summary

LaSalle Medical Associates IPA seeks a Claims Manager to oversee the daily operations of the Claims Department within the MSO and supervise Claims Examiners to ensure accurate, timely adjudication of professional and institutional claims in line with health plan contracts and regulations.

The role focuses on monitoring claims inventory and quality metrics, maintaining turnaround times, and ensuring compliance with DMHC, CMS, and DHCS requirements while supporting delegated managed care

Qualifications

• Minimum: High School diploma or equivalent.
• Preferred: Bachelor’s degree in Healthcare Administration, Business Administration, or related field.
• Minimum: At least five years of managed care claims processing experience. Two or more years of supervisory or leadership experience.
• Preferred: Experience in MSO, IPA, or delegated managed care environment; Medicare, Medi-Cal, Commercial claims; claims systems like EZ Cap, EPIC.

Responsibilities

• Oversee daily operations of the Claims Department within the MSO.
• Lead and supervise Claims Examiners to ensure accurate adjudication of professional and institutional claims.
• Monitor claims inventory, production, and quality metrics to meet turnaround time standards.
• Ensure regulatory compliance with DMHC, CMS, DHCS requirements and audits.

Skills

Claims processing

Regulatory compliance

Leadership

Analytics

Education

High School diploma or equivalent

Bachelor’s degree in Healthcare Administration or related field

Tools

EZ Cap

EPIC

Job description

Description

JOB SUMMARY

The Claims Manager is responsible for overseeing the daily operations, performance, and regulatory compliance of the Claims Department within the Managed Services Organization (MSO). This role provides leadership and supervision to Claims Examiners and ensures the accurate, timely, and compliant adjudication of professional and institutional claims in accordance with health plan contracts, regulatory requirements, and organizational policies.

The Claims Manager monitors claims inventory, production, and quality metrics, ensures adherence to turnaround time standards, and supports operational efficiency and compliance with federal and California regulatory requirements, including Department of Managed Health Care (DMHC), Centers for Medicare & Medicaid Services (CMS), and Department of Health Care Services (DHCS) requirements where applicable.

This position plays a critical role in ensuring claims processing accuracy, maintaining provider satisfaction, protecting organizational financial integrity, and supporting delegated managed care operations.

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High School diploma or equivalent required.

Preferred: Bachelor’s degree in Healthcare Administration, Business Administration, or related field.

Experience

Minimum: At least five years of managed care claims processing experience. Two or more years of supervisory or leadership experience. Experience processing professional and institutional claims.

Preferred: Experience in MSO, IPA, or delegated managed care environment. Experience with Medicare, Medi-Cal, Commercial, and managed care claims. Experience with claims systems such as EZ Cap, EPIC, or similar platforms. Experience supporting regulatory and delegation audits.

Certification(s)

Preferred: Certified Professional in Healthcare Quality (CPHQ)

Skills, Knowledge & Abilities

• Strong knowledge of managed care claims processing and adjudication.
• Knowledge of CPT, HCPCS, ICD-10, and UB-04 claim processing standards.
• Knowledge of DMHC, CMS, DHCS, and managed care regulatory requirements.
• Strong leadership and staff supervision skills.
• Strong analytical, organizational, and problem-solving skills.
• Ability to assess workload and staffing requirements.
• Excellent written and verbal communication skills.
• Proficiency in Microsoft Office Suite, including Excel.
• Ability to manage multiple priorities in a deadline-driven environment.
• Ability to maintain confidentiality and data integrity.
• Ability to collaborate effectively with internal and external stakeholders.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical demands described here are represented by those that must be met by an employee to successfully perform the essential functions of this job. Work is primarily performed in an office or hybrid office environment and involves prolonged periods of sitting, computer use, and data review. The role requires sustained concentration, analytical thinking, and attention to detail to ensure claims accuracy and regulatory compliance. Occasional lifting of materials up to approximately 10–20 pounds may be required. The position may require extended work hours or weekend work to meet operational and regulatory deadlines.

PAY RANGE

$87,360 - $97,760 / annually