Strategic Leader, Claims Execution & Operations

Gold Coast Health Plan; Camarillo (CA); On-site; USD 157,303 - 262,697; Full time

Job summary

Gold Coast Health Plan is seeking a senior leader to drive the Claims Execution function in California. The role requires strategic oversight of claims processing, intake, PDR, encounters, and reimbursements, with a focus on efficiency, accuracy, and compliance.

You will manage inventory, capacity, and performance while guiding cross-functional teams and external partners. You will lead operational change initiatives, ensure regulatory compliance, and build a culture of accountability and

Qualifications

• Experience leading managed care claims operations and complex workflow.
• Knowledge of Medi-Cal, Medicare, and other payer operations.
• Experience overseeing outsourced claims processing and vendor relationships.
• Experience implementing regulatory compliance and process improvements.

Responsibilities

• Provide strategic and operational leadership for Claims Execution to ensure timely, accurate, compliant processing.
• Direct day-to-day management of claims work queues including intake, complex processing, PDR, encounters, reimbursements.
• Manage inventory, capacity planning, queue governance, aging, and performance metrics.
• Oversee BPO vendor performance including SLAs, quality, and improvements.
• Monitor risks, capacity constraints, backlog trends, and corrective actions.
• Lead and develop Claims Execution staff and foster accountability.
• Collaborate with internal teams to resolve issues and support enterprise goals.
• Ensure compliance with federal/state regulations and implement new regulatory requirements.
• Define procedures, controls, and SOPs for consistency and efficiency.
• Represent Claims Execution in governance meetings and vendor discussions.

Skills

Claims processing

Operational leadership

Inventory management

Regulatory compliance

Vendor management

Process improvement

Cross-functional collaboration

Service delivery

Quality assurance

Education

Bachelor's degree in Business Administration or Healthcare Administration

Equivalent combination of education and experience

Master's degree preferred

Tools

MS Office

Job description

Gold Coast Health Plan is seeking a senior leader to drive the Claims Execution function in California. The role requires strategic oversight of claims processing, intake, PDR, encounters, and reimbursements, with a focus on efficiency, accuracy, and compliance.

You will manage inventory, capacity, and performance while guiding cross-functional teams and external partners. You will lead operational change initiatives, ensure regulatory compliance, and build a culture of accountability and