Strategic Claims Director – Health Plan

Contra Costa County; Martinez (CA); On-site; USD 170,000 - 230,000; Full time

Job summary

Contra Costa Health Plan seeks a Health Plan Division Director – Exempt (Claims Director) to lead its claims operations with a focus on accuracy, compliance, and timely payments across Medi-Cal, Medicare, and commercial lines.

You will work with executive leadership to set strategic direction, oversee adjudication, payment integrity, and vendor relationships, and drive continuous improvement in a large public health plan.

Qualifications

• Possession of a master’s degree in a related field or higher is required.
• Experience leading health plan claims operations with regulatory oversight is essential.
• Strong leadership, communication, and vendor management skills are expected.

Responsibilities

• Provide leadership and oversight of all CCHP claims operations including adjudication, adjustments, payment integrity, and recovery activities.
• Direct, coach, and evaluate managers and supervisors responsible for daily claims operations.
• Oversee clearinghouses and other claims-related vendors and monitor contract performance and issue resolution.
• Direct the use and optimization of Epic Tapestry for claims adjudication, payment rules, edits, and reporting; ensure changes are tested and implemented.
• Ensure full compliance with federal, state, and local regulations (DHCS, DMHC, CMS).
• Establish and monitor KPIs related to timeliness, accuracy, financial controls, and regulatory compliance.
• Serve as primary liaison for claims-related matters with providers, county partners, auditors, and regulatory agencies.
• Identify operational risks and corrective actions; report to executive leadership.

Skills

Managed Care Leadership

Medicaid & Medicare knowledge

Strategic Thinker

Strong Communicator

Solution-Oriented

Professional & Collaborative

Discreet & Judicious

Education

Master’s degree in Business Administration / Health Care Administration / Public Administration / Public Health

Bachelor’s degree + 2 years qualifying experience substitution

Job description

Contra Costa Health Plan seeks a Health Plan Division Director – Exempt (Claims Director) to lead its claims operations with a focus on accuracy, compliance, and timely payments across Medi-Cal, Medicare, and commercial lines.

You will work with executive leadership to set strategic direction, oversee adjudication, payment integrity, and vendor relationships, and drive continuous improvement in a large public health plan.