Remote Claims Strategy & Operations Governance Lead

ADP, Inc.; French Camp (CA); Remoto; USD 111.000 - 160.000; Tempo integral

Benefícios oferecidos por esta vaga

Health coverage

Wellness program

Paid time off

Retirement benefits

Remote work eligibility

Resumo da vaga

ADP, Inc. is seeking a Manager, Claims Strategy & Operations Governance to lead governance, operational strategy, quality assurance, and recovery across Claims Operations.

You will supervise QA and Recovery/Payment Integrity, coordinate with Claims Operations and related teams, and drive readiness for audits and regulatory requirements. The role requires strategic thinking, strong communication, and the ability to influence across multiple levels without direct authority, while guiding

Qualificações

• 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.
• Strategic mindset with ability to connect operational activities to enterprise priorities and future needs.
• Ability to influence and gain commitment across functional areas without direct authority.
• Strong communication skills, including written, verbal, presentation, and executive-level communication.
• Strong organizational savvy, complexity management, resourcefulness, decision quality, and ability to maneuver through cross-functional dynamics.

Responsabilidades

• 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.
• Facilitates alignment across Claims Operations, Configuration, Provider Disputes, Adjustments, Recovery, QA, Training, and other functional partners to ensure cohesive workflow design, coordinated execution, and unified problem-solving
• Coordinates transformation initiatives across claims-related functions, including workflow redesign, stabilization efforts, reporting modernization, recovery modernization, and operational readiness activities.
• Develops and maintains governance reporting packages, executive summaries, performance dashboards, and initiative tracking documentation to support leadership visibility and decision-making.
• Identifies operational, regulatory, and cross-functional risks; recommends mitigation strategies and supports the implementation of long-term controls.
• Oversees development, implementation, and maintenance of documentation including workflows, procedures, routing rules, governance logs, dependency maps, and operational frameworks.
• Serves as escalation point for complex claims, regulatory, recovery, and quality issues; researches concerns, facilitates resolutions, and coordinates communication with leadership.
• Collaborates with internal teams to prepare for regulatory audits and external reviews; supports readiness, documentation preparation, corrective action plan monitoring, and cross-functional follow-through.
• Supports fraud, waste, and abuse prevention efforts through coordinated analytics, issue identification, and operational escalation processes.
• Supervises quantitative and qualitative analyses across QA, Recovery, and governance areas; interprets data, develops insights, and recommends process improvements.
• Partners with Training and other stakeholders to support readiness, operational training needs, and workflow enablement, maintaining dotted‑line governance of the Training function.
• Maintains dotted‑line governance of Provider Disputes (PDR) and Adjustments; ensures alignment, readiness, and cross-functional coordination, with the ability to assume full ownership of these operational areas as organizationally assigned.
• Promotes and maintains an environment that supports HPSJ’s strategy, vision, mission, and values.

Conhecimentos

Medi-Cal regulations knowledge

Claims operations knowledge

Audit processes

Data analysis

Governance frameworks

Strategic thinking

Influence without authority

Communication skills

Cross-functional collaboration

Formação

Bachelor’s Degree in a related field

Ferramentas

Word

Excel

Descrição da vaga

ADP, Inc. is seeking a Manager, Claims Strategy & Operations Governance to lead governance, operational strategy, quality assurance, and recovery across Claims Operations.

You will supervise QA and Recovery/Payment Integrity, coordinate with Claims Operations and related teams, and drive readiness for audits and regulatory requirements. The role requires strategic thinking, strong communication, and the ability to influence across multiple levels without direct authority, while guiding