Manager, Claims Compliance

Job Summary

The Manager, Claims Compliance is responsible for ensuring Core Administrative Operations meet federal, state, and contractual regulatory requirements. This position oversees regulatory interpretation, operational compliance monitoring, corrective action oversight, and the development and delivery of operational training across all claims-related functions. The Manager establishes and maintains documentation standards, partners with operational leaders to evaluate compliance risk, and develops training and readiness programs that ensure staff consistently understand rules, follow procedures, and meet regulatory expectations.

The Manager serves as the primary compliance liaison for Core Administrative Operations, ensuring that regulatory requirements are embedded into workflows, policies, and training. This position partners closely with the key stakeholders to ensure alignment between compliance oversight, audit findings, training programs, corrective action planning, and quality outcomes. The Manager leads a team responsible for training development, operational compliance validation, regulatory change management, policy governance, and operational readiness. The Manager fosters a culture of compliance, accuracy, clarity, and continuous learning across the Core Administrative Operations ecosystem.

The Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Participates and make recommendations on the department's strategic planning and/or long-term decision-making.

Duties

Ensures that Core Administrative Operations has a strong and sustainable compliance foundation.  Interprets regulatory guidance, identifies compliance risks, develops training that operationalizes regulatory changes, and builds documentation that ensures accuracy and audit readiness.  Strengthens operational integrity, improves adherence to state/federal requirements, and equips staff with the knowledge and tools needed to process claims accurately and consistently through cross-functional collaboration, transparent communication, and structured oversight.

Monitors compliance with regulatory agencies, NCQA, and contractual requirements related to claims processing, adjustments, disputes, configuration, and payment accuracy. Interprets new and updated regulations, determines operational impacts, and guides leaders in implementing compliant workflows across key stake holders.  Oversees compliance monitoring and internal validation activities, ensuring critical regulations (TATs, notices, interest, benefit/payment rules, documentation) are consistently met. Serves as subject-matter expert on regulatory and contractual requirements affecting claims and related administrative functions. Partners with the key stakeholders to ensure compliance findings are integrated into testing programs, CAP validation, and quality standards.

Designs, implements, and oversees comprehensive operational training programs across cross functional teams.  Develops training curricula for benefit/authorization interpretation, regulatory updates, pricing/reimbursement requirements, provider contract terms, system logic impacts, and other operational topics. Ensures training incorporates regulatory expectations, audit findings, corrective action themes, and emerging rules. Maintains an enterprise training repository (SOPs, desk procedures, job aids, reference guides) to ensure consistent understanding and execution. Provides onboarding training, cross-training programs, and targeted training for new systems, regulatory changes, and operational enhancements. Partners with key stakeholders to ensure staff have the knowledge required to maintain accuracy in a highly regulated environment.

Duties Continued

Oversees creation, maintenance, and governance of policies, procedures, desk-level workflows, and job aids across Core Admin Ops. Ensures documentation is aligned with current regulatory requirements, contractual obligations, and operational processes. Maintains structured documentation approval processes and version control to support audit readiness and compliance transparency. Partners with operational leaders and QA to ensure procedures align with audit findings, corrective actions, and quality standards.

Leads operational readiness planning for regulatory or contractual changes affecting claims payment, provider reimbursement, data requirements, notices, timelines, and related administrative rules. Collaborates with key stakeholders to identify impacts, design compliant solutions, and update training/materials. Develops and manages implementation plans for required changes, ensuring consistency across teams and sustainable compliance. Supports internal and external audits by preparing documentation, participating in sample review, and coordinating with QA and operational leaders. Tracks regulatory trends and proactively identifies potential compliance risks or exposure areas.

Develops and oversees corrective actions related to compliance gaps, operational deficiencies, and audit findings. Ensures corrective actions incorporate training, policy updates, and process changes to drive sustainable improvement. Partners key stakeholder to validate Corrective Action Plan (CAP) effectiveness through testing, monitoring, and data-driven assessments. Tracks patterns of compliance gaps and collaborates with operational leaders to implement preventive improvements.

Serves as the primary compliance advisor to operational leaders within cross functional business units. Supports management with regulatory interpretation, operational analysis, compliance risks, and recommended mitigation strategies. Represents Claims Compliance in governance meetings, operational readiness discussions, and regulatory working groups. Partners with Analytics and operational reporting teams to monitor compliance metrics, operational adherence, and trend analyses.

Manages, leads, trains, and develops a team responsible for training, documentation, compliance monitoring, and regulatory interpretation. Ensures staff maintain deep working knowledge of regulatory requirements and operational processes. Builds a culture grounded in data integrity, critical thinking, and supports proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement. Manage staff, including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.

Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Responsible for reporting, budgeting, and policy implementation.
Perform other duties as assigned.

Education Required

Education Preferred

Experience

Required:

At least 6 years of experience in claims compliance, regulatory oversight, or related experience in a managed care environment.

At least 4 years of experience leading, supervising/managing staff.

Equivalency:  Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.

Experience leading teams, projects, initiatives, or cross-functional groups.

Experience with claims processing, adjustments, payment methods, and associated core administrative operations.

Experience in Medicaid, Medicare, and Commercial managed care lines of business.

Experience developing training programs or documentation for claims or other administrative operations.

Deep experience interpreting regulations, provider contracts, payment methodologies, and managed care benefit structures.

Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing.

Experience supporting or preparing for regulatory audits ((Department of Managed Health Care (DMHC), California Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS)) including corrective action planning.

Skills

Required:

Strong operational understanding, and the ability to translate complex regulatory and contractual requirements into practical, operational execution. 

Deep knowledge of claims adjudication, benefit structures, provider contracting, DoFR, pricing rules, and coding standards (Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS)/ International Classification of Diseases (ICD)/ Diagnosis Related Group (DRG)).

Strong understanding of federal/state regulatory frameworks governing claims.

Exceptional ability to translate regulatory requirements into operational training and documentation.

Strong analytical, problem-solving, and compliance monitoring skills.

Exceptional interpersonal, verbal, and written communication skills, including executive communication with ability to produce audit-ready documentation.

Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously; strong attention to detail.

Proven ability to work collaboratively and influence across multiple functional areas.

Proficiency of Microsoft Office suite, including Word, Excel, Teams and PowerPoint.

Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.

Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.

Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.

Must have a deep understanding of financial principles.

Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.

Demonstrated ability to make informed decisions.

Strong verbal, written communication and presentation skills.

Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.

Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information