Director, Claims Execution & Operational Excellence

Gold Coast Health Plan; California (MO); On-site; USD 157,303 - 262,697; Full time

Job summary

Gold Coast Health Plan is seeking an experienced executive to lead Claims Execution, ensuring timely, compliant processing across all queues and vendors. You will drive inventory management, capacity planning, and performance metrics to optimize operations in a regulated healthcare payer environment.

The role requires strong leadership, collaboration with IT, Compliance, and Finance, and a track record of improving service delivery while controlling costs. California-focused pay range applies.

Qualifications

• Bachelor's degree in a related field or equivalent experience.
• 8+ years of managed care claims operations experience.
• 5+ years of leadership in operational teams.
• Experience with outsourced services/BPO ownership is desirable.
• Experience with inventory management and capacity planning.
• Knowledge of AB 1455 and other PDR regulations.
• Strong collaboration across departments.

Responsibilities

• Provide strategic and operational leadership for Claims Execution, ensuring timely and compliant processing.
• Direct day-to-day management of operational work queues and related functions.
• Serve as SME in inventory management, workload prioritization, and capacity planning.
• Establish standards, SLAs, and performance metrics across Claims Execution.
• Oversee vendor performance, quality, and continuous improvement.
• Monitor inventories, risks, backlog trends, and regulatory compliance.
• Lead and develop management and staff, fostering accountability and excellence.
• Collaborate with cross-functional partners to resolve issues and execute initiatives.

Skills

Claims processing

Provider dispute resolution

Operational leadership

Regulatory compliance

Workflow optimization

Education

Bachelor's degree in Healthcare Administration

Master's degree preferred

Tools

MS Office

Job description

Gold Coast Health Plan is seeking an experienced executive to lead Claims Execution, ensuring timely, compliant processing across all queues and vendors. You will drive inventory management, capacity planning, and performance metrics to optimize operations in a regulated healthcare payer environment.

The role requires strong leadership, collaboration with IT, Compliance, and Finance, and a track record of improving service delivery while controlling costs. California-focused pay range applies.