Director, Claims Operations & Strategy

Ventura County Medi-Cal Managed Care Commission; United States; Remote; USD 157,000 - 263,000; Full time

Job summary

Gold Coast Health Plan is seeking a senior leader to manage Claims Execution, ensuring timely, compliant, and cost-effective operations across intake, complex claims, and reimbursements. The role leads operational performance, capacity planning, and co-ordination with IT, Finance, Compliance, and provider networks to drive service quality.

Strong focus on vendor management, process improvement, and regulatory adherence is required.

Qualifications

• Bachelor’s degree in Healthcare Admin, Business, or related field, or equivalent experience.
• 8+ years in managed care claims operations with leadership responsibility.
• 5+ years leading operational teams within a managed care/health plan environment.
• Experience overseeing outsourced services (BPO) is desirable.
• Experience leading workflow redesign and automation initiatives.

Responsibilities

• Provides strategic and operational leadership for Claims Execution, ensuring timely, compliant, and cost-effective execution.
• Directs day-to-day management of operational work queues including intake, complex claims, PDR, encounters, and reimbursements.
• Serves as SME in inventory management, capacity planning, queue governance, aging management, and performance.
• Establishes standards, SLAs, and dashboards to ensure consistent execution and regulatory compliance.
• Provides oversight of BPO claims processing vendor performance and continuous improvement.
• Monitors inventories, risks, backlog trends, and takes corrective actions to maintain performance.
• Leads and develops management and staff within Claims Execution to foster accountability and service.
• Allocates resources to balance workloads and achieve service levels.
• Partners with Claims Ops to identify defects, automation opportunities, and improvements.
• Collaborates with Configuration, IT, Finance, Compliance, Provider Network Ops, and others to resolve issues.
• Ensures compliance with federal/state requirements and contractual obligations.
• Oversees readiness for new regulatory requirements, initiatives, and changes.
• Tracks performance metrics and takes action to achieve goals.
• Develops and maintains SOPs and controls for consistency and efficiency.
• Represents Claims Execution in governance meetings and cross-functional forums.
• Identifies opportunities to improve provider/member experience by reducing defects and improving turnaround times.
• Performs other duties as assigned.

Skills

Strategic leadership

Claims operations

Vendor management

Regulatory compliance

Process improvement

Education

Bachelor’s degree in relevant field

Master’s degree preferred

Equivalent combination of education/experience

Tools

MS Office

Job description

Gold Coast Health Plan is seeking a senior leader to manage Claims Execution, ensuring timely, compliant, and cost-effective operations across intake, complex claims, and reimbursements. The role leads operational performance, capacity planning, and co-ordination with IT, Finance, Compliance, and provider networks to drive service quality.

Strong focus on vendor management, process improvement, and regulatory adherence is required.