Remote Claims Strategy and Operations Governance Manager

Health Plan of San Joaquin/Mountain Valley Health Plan; French Camp (CA); Remote; USD 120,000 - 170,000; Full time

Benefits offered by this job

Medical coverage and benefits

Remote work in California

Paid time off and holidays

CalPERS retirement options

Job summary

Health Plan of San Joaquin seeks a Manager, Claims Strategy & Operations Governance to lead governance, operational strategy, QA, and recovery across Claims Operations at the enterprise level. You will oversee QA and Recovery and coordinate with Claims Operations, PDR, Adjustments, Training, and related teams for audits and regulatory readiness.

The role requires strategic thinking, strong communication, and the ability to influence without direct authority.

Qualifications

• In-depth knowledge of Medi-Cal regulations and state-sponsored program requirements.
• Strong understanding of claims operations including processing, adjustments, PDR, recovery, QA, configuration, and their cross-functional interactions.
• Strong knowledge of audit processes, quality metrics, recovery methodologies, claims processing systems, and industry-standard payment practices.
• Strong analytical skills with ability to distill concepts, synthesize data, draw conclusions, and identify implications.
• In-depth knowledge of governance frameworks, operational readiness, project coordination, and execution management.

Responsibilities

• Develops strategic and operational plans that align departmental objectives with enterprise-wide priorities; monitors progress and implements appropriate interventions.
• Establishes and maintains governance infrastructure for Claims Operations and related functions, including meeting cadence, reporting packages, dependency mapping, dashboards, initiative logs, and action item follow-through.
• Provides dotted ‑ line governance oversight of Claims Operations, including performance monitoring, priority alignment, issue escalation tracking, and operational readiness assessment.
• Directly oversees Quality Assurance, including audit processes, quality metrics, error trends, and corrective action plans to support quality and compliance improvements.
• Owns Recovery / Payment Integrity programs, including audit oversight, financial and operational reporting, savings validation, vendor coordination, regulatory compliance, and execution readiness.

Skills

Medi-Cal regs

Claims operations

Governance frameworks

Audits & compliance

Analytical skills

Executive communication

Cross-functional collaboration

Education

Bachelor’s Degree

Tools

Word

Excel

Job description

Health Plan of San Joaquin seeks a Manager, Claims Strategy & Operations Governance to lead governance, operational strategy, QA, and recovery across Claims Operations at the enterprise level. You will oversee QA and Recovery and coordinate with Claims Operations, PDR, Adjustments, Training, and related teams for audits and regulatory readiness.

The role requires strategic thinking, strong communication, and the ability to influence without direct authority.