Claims Operations Lead - Audit & Process Excellence

Verda Healthcare; Huntington Beach (CA); Presencial; USD 95.000 - 120.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

401(k)

Paid time off (vacation, holiday, sick

Health insurance

Dental insurance

Vision insurance

Life insurance

Descripción de la vacante

Verda Healthcare, Inc. is seeking an Assistant Director, Claim Operations in Huntington Beach, CA to oversee daily claims processing and reconciliation, ensuring CMS and state compliance while supporting audits and operational excellence.

This leadership role partners with Claims Operations, Compliance, Finance, IT and delegated IPAs to optimize workflows, manage risk, and drive reporting and improvement initiatives.

Formación

• Bachelor’s degree or equivalent in related field preferred.
• Minimum 3+ years of experience in health plan, managed care, Medicare Advantage, IPA, TPA, or claims operations.
• Working knowledge of claims intake, adjudication, pricing, payment, reconciliation, denials, and provider disputes.
• Familiarity with CMS, state, health plan, and delegated entity requirements.
• Experience with claims systems and reporting tools; proficiency in Microsoft Office.
• Strong organizational, analytical, communication, and follow-up skills.

Responsabilidades

• Support the Claims Director in monitoring daily claims operations, including intake, adjudication, payment, reconciliation, aging inventory, pending claims, and high-dollar claims.
• Track, document, and help resolve escalated claims issues involving providers, IPAs, internal departments, vendors, and delegated entities.
• Maintain claims dashboards, issue trackers, reconciliation reports, audit documentation, and operational reporting for leadership review.
• Ensure compliance with CMS, state, health plan, and internal requirements; keep processes and reports audit-ready.
• Assist with payment integrity reviews, including pricing validation, coding accuracy, and duplicate claim detection.
• Coordinate with stakeholders to support timely claim issue resolution and operational alignment.
• Prepare data, reports, and materials for internal reviews, audits, and leadership meetings.
• Support claim-related projects, system implementations, testing, and regulatory changes.
• Communicate effectively regarding claims escalations, provider inquiries, and project updates.
• Oversee daily claims routing and collaborate with IT, Delegation group, and Vendors.

Conocimientos

Claims operations

Analytical thinking

Communication

Attention to detail

Project coordination

Educación

Bachelor’s degree in business, healthcare administration, finance, public health, or a related field

Herramientas

Microsoft Excel

Descripción del empleo

Verda Healthcare, Inc. is seeking an Assistant Director, Claim Operations in Huntington Beach, CA to oversee daily claims processing and reconciliation, ensuring CMS and state compliance while supporting audits and operational excellence.

This leadership role partners with Claims Operations, Compliance, Finance, IT and delegated IPAs to optimize workflows, manage risk, and drive reporting and improvement initiatives.