Senior Manager, Claims Health Plan Readiness

CareMore Health Management Services, LLC; California; Hybrid; USD 130,000 - 195,000; Full time

Benefits offered by this job

3 weeks PTO

Medical, Dental, Vision coverage

401(k) with match

Employee Wellness

Other Employee Discounts

Job summary

Mosaic Health is seeking a Senior Manager, Claims Health Plan Readiness to lead regulatory compliance, audit readiness, and payment integrity across claims operations. This fully remote role requires aligning CMS and health plan requirements with operational practices and cross-functional collaboration across Compliance, Finance, IT, and Clinical Operations.

The ideal candidate will have extensive CMS knowledge, 8–10 years in healthcare claims, and 3–5 years in leadership, with a proven ability

Qualifications

• Bachelor's degree in a related field or equivalent relevant experience.
• 8–10+ years of progressive healthcare claims, adjudication, reimbursement, or regulatory compliance experience.
• 3–5+ years of leadership experience managing teams, team leaders, or complex cross-functional operational programs.
• Extensive knowledge of CMS requirements and health plan regulatory compliance, including Medicare, Medicaid, managed care, coding standards, and claims administration systems.
• Hands-on experience leading claims-related health plan and CMS audits, including audit preparation, documentation and evidence coordination, audit responses, remediation, and corrective action follow-through.
• Strong analytical, communication, people leadership, and change management skills.

Responsibilities

• Regulatory compliance strategy and governance: Develop and execute claims health plan readiness strategies with regulatory compliance and health plan and CMS audit readiness as core priorities.
• Claims operations and compliance leadership: Lead multiple teams or functional workstreams supporting compliant claims adjudication, reimbursement accuracy, health plan and CMS audits, and corrective action execution.
• Health plan and CMS audit leadership: Lead the preparation, coordination, and execution of claims-related health plan and CMS audits, including Medicare, Medicaid, managed care, and payer audits.
• Regulatory implementation and compliance controls: Translate CMS and other applicable regulatory changes into scalable policies, claims system requirements, operating procedures, and quality controls.
• Compliance issue resolution and corrective actions: Direct the analysis and resolution of systemic adjudication errors, denials, coding issues, payment discrepancies, and recurring findings.
• Systems and payment integrity improvement: Sponsor enhancements to claims systems, workflows, automation, payment integrity, and coding controls.
• Compliance monitoring and audit reporting: Establish and monitor metrics to assess claims performance, audit readiness, and corrective action progress.
• People leadership and cross-functional partnership: Lead resource planning, team performance, coaching, and development across multiple functions.

Skills

Regulatory compliance

CMS audits

Leadership

Cross-functional collaboration

Education

Bachelor's degree

Advanced degree

CBCS credential

Tools

Facets

QNXT

EDI 837/835

Job description

Job Description Summary

Work Location: Fully remote. This position requires working standard business hours in Pacific Time (PT). Position Overview We are seeking an experienced Senior Manager, Claims Health Plan Readiness with a strong focus on regulatory compliance and leading health plan and Centers for Medicare & Medicaid Services (CMS) audits. This role leads claims regulatory compliance, audit preparation and execution, adjudication oversight, and payment accuracy across assigned operations. You will establish functional priorities, lead teams and cross-functional improvement initiatives, and translate complex regulatory requirements into effective operational practices. Working closely with Compliance, Finance, IT, and operational leaders, you will strengthen regulatory controls, coordinate audit responses and corrective actions, resolve systemic claims issues, and improve claims performance.

Key Responsibilities

• Regulatory compliance strategy and governance: Develop and execute claims health plan readiness strategies with regulatory compliance and health plan and CMS audit readiness as core priorities. Establish performance standards, maintain regulatory controls across assigned claims functions, and align improvement initiatives with operational and compliance needs.
• Claims operations and compliance leadership: Lead multiple teams or functional workstreams supporting compliant claims adjudication, reimbursement accuracy, health plan and CMS audits, and corrective action execution. Coordinate priorities and accountability to embed compliance and ongoing audit readiness into daily operations.
• Health plan and CMS audit leadership: Lead the preparation, coordination, and execution of claims-related health plan and CMS audits, including Medicare, Medicaid, managed care, and payer audits. Coordinate audit documentation, supporting evidence, stakeholder responses, and audit inquiries. Direct risk assessments, remediation planning, corrective action execution, and follow-through on findings to address compliance gaps and prevent recurrence.
• Regulatory implementation and compliance controls: Translate CMS and other applicable regulatory changes into scalable policies, claims system requirements, operating procedures, and quality controls. Partner with relevant stakeholders to integrate requirements into day-to-day operations and maintain documentation supporting compliance and audit readiness.
• Compliance issue resolution and corrective actions: Direct the analysis and resolution of systemic adjudication errors, denials, coding issues, payment discrepancies, and recurring health plan and CMS audit findings. Coordinate corrective actions that address underlying causes, close compliance gaps, and support sustained improvement.
• Systems and payment integrity improvement: Sponsor enhancements to claims systems, workflows, automation, payment integrity, and coding controls, including controls related to ICD-10-CM, CPT, HCPCS, NCCI, and MUE requirements.
• Compliance monitoring and audit reporting: Establish and monitor operational and compliance metrics to assess claims performance, health plan and CMS audit readiness, audit findings, and corrective action progress. Communicate compliance risks, audit results, and actionable recommendations to senior leadership.
• People leadership and cross-functional partnership: Lead resource planning, team performance, coaching, and professional development. Build alignment across Compliance, Finance, IT, Clinical Operations, Provider Relations, and Payment Integrity to execute shared priorities and operational improvements.

Required Qualifications

• Bachelor's degree in a related field or equivalent relevant experience.
• 8–10+ years of progressive healthcare claims, adjudication, reimbursement, or regulatory compliance experience.
• 3–5+ years of leadership experience managing teams, team leaders, or complex cross-functional operational programs.
• Extensive knowledge of CMS requirements and health plan regulatory compliance, including Medicare, Medicaid, managed care, coding standards, and claims administration systems.
• Demonstrated hands‑on experience leading claims-related health plan and CMS audits, including audit preparation, documentation and evidence coordination, audit responses, remediation, and corrective action follow-through. Proven ability to implement regulatory requirements, improve operational performance, and influence senior stakeholders.
• Strong analytical, communication, people leadership, and change management skills.

Preferred Qualifications

• Advanced degree.
• CBCS or a comparable credential.
• Experience with Medicare Advantage or Medicaid managed care.
• Experience with Facets, QNXT, or similar claims administration platforms.
• Experience with EDI 837/835 transactions, auto‑adjudication, or claims system implementation.

Benefits

• 3 weeks PTO & 8 paid holidays
• Medical, Dental, Vision Employer Paid Basic Life & Short Term Disability coverage (goes into effect after 1 year of full-time employment)
• 401(k) with match
• Employee Wellness
• Other Employee Discount programs like Tickets at Work and cell phone discounts
• Other benefits: Dependent Care FSA, Voluntary Life, Long Term Disability, Critical Illness, Pet Insurance, and more

About Mosaic Health

Mosaic Health is a national care delivery platform focused on expanding access to comprehensive primary care for consumers with coverage across Commercial, Individual Exchange, Medicare, and Medicaid health plans. The Business Units which comprise Mosaic Health, including apree health, Millennium Physician Group, and CareMore Health, are multi-payer and serve nearly one million individuals across 19 states, providing them with access to high quality primary care, integrated care teams, personalized navigation, expanded digital access, and specialized services for higher-need populations. For more information, visit www.mosaichealth.com.

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Compensation Range

Compensation Range: $130,159.00 to $195,238.00 The anticipated base salary range represents the Company's good‑faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.