Manager, Claims Quality Assurance

Job Summary

The Manager, Claims Quality Assurance (QA) is responsible for managing and leading the operational quality program focused on preventative and predictive orientation that evaluates and strengthens accuracy across the entire claims lifecycle from receipt and intake through adjudication, adjustments, disputes, and post-payment verification. This position ensures L.A. Care’s Core Administrative Operations maintain high processing accuracy, strong control points, and consistent application of benefits, provider contracts, coding standards, and regulatory requirements.

The Manager oversees operational QA testing, examiner-level audit programs, quality scoring, root-cause identification, and corrective action validation. This position also supports regulatory readiness through mock audit participation, audit universe/sample creation, and quality documentation preparation. Works in partnership with leadership. This position manages staff and partners closely with cross functional key stake holders to drive upstream improvements while aiming to remove rework.

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

Builds a disciplined quality review framework that increases first-pass accuracy, reduces preventable defects, strengthens upstream controls, and ensures consistent application of rules across the claims lifecycle. Through rigorous audit practices, validation of corrective actions, and structured feedback loops, this role enhances operational predictability and ensures readiness for regulatory audits.

Oversees audits across the entire operational claims lifecycle including claim intake, data entry, adjudication, pricing, coding accuracy, benefit interpretation, provider contract application, and documentation. Monitors and validates adjustment processing, provider disputes resolutions, and post-payment quality outcomes tied to Payment Integrity remediation. Ensures quality reviews measure accuracy, consistency, and compliance with policies, benefit structures, provider contracts, coding standards, pricing methodologies, and regulatory expectations. Ensures QA findings are accurate, evidence-based, and actionable for operational leaders.

Designs and oversees the claims QA audit methodology, including sampling standards, audit frequency, scoring tools, examiner scorecards, and quality thresholds. Co-leads claims components of mock audits for regulatory agencies, and related review bodies. Prepares audit universes, conducts sample reviews, organizes evidence, and ensures accuracy of documentation for internal/external audits. Ensures QA processes meet expectations for regulatory audit readiness.

Conducts root-cause analysis on quality findings to identify systemic drivers behind defects or inconsistencies.

Works with cross functional key stakeholders to implement and validate corrective actions. Confirms that corrective actions address underlying issues and reduce recurrence. Tracks error trending to identify early signals of operational or regulatory risk.

Maintains claims QA guidelines, audit manuals, sampling methodologies, scoring rules, and documentation requirements. Develops quality dashboards, trend analyses, and quality scorecards for Core Administrative Operations leadership. Ensures quality results are communicated clearly, consistently, and with actionable recommendations. Monitors adherence to quality standards across examiners, analysts, and adjustment staff.

Duties Continued

Partners with Claims Administration to align QA results with workflow changes, training needs, and performance expectations. Coordinates with Configuration’s system QA team to align operational audit insights with system testing requirements (no ownership of configuration QA). Works with Payment Integrity to validate accuracy of post-pay adjustments and ensure systemic issues are fed into preventive controls. Collaborates with Compliance & Training to ensure QA findings inform training content, SOP updates, and policy interpretation. Supports SVU and the Tiger Team by validating accuracy of complex claim reviews and identifying upstream contributors to identified issues.

Establishes performance metrics, audit schedules, and competency expectations. Builds a culture grounded in analytical precision, data integrity, critical thinking, and investigative rigor.  Capitalizes on metrics for proactive indicators of risks, issue identification, cross-functional communication, accountability, transparency, and execute 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 5 years of experience claims operations, claims auditing, claims QA, or complex claims operational functions.

At least 3 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 in Medicaid, Medicare, and Commercial managed care lines of business.

Hands-on experience conducting claims testing or accuracy audits.

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

Demonstrated experience with high complexity claims review and RCA.

Experience supporting or preparing for regulatory audits (DMHC, DHCS, CMS).

Demonstrated experience analyzing claims defects and validating corrective actions.

Preferred:

Coding experience or equivalent knowledge.

Experience partnering with system configuration teams.

Experience with quality program design and audit governance.

Skills

Required:

Deep understanding of standard claims processing systems and claims data analysis. Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing. Deep knowledge of claims adjudication, benefit structures, provider contracting, DoFR, pricing rules, and coding standards. Advanced knowledge of contractual pricing mechanisms for inpatient, outpatient, Long Term Care (LTC) and ancillary services.

Advanced analytical and root-cause analysis skills. Deep knowledge of relevant regulatory requirements. Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously; strong attention to detail. Ability to track and trend the metrics associated with auditor production. Proficient of Microsoft Office suite, including Word, Excel, Teams and PowerPoint. Highly collaborative and maintain a consultative style with ability to establish credibility quickly with all levels of management across multiple functional areas. Exceptional interpersonal, verbal, and written communication skills, including executive communication with ability to produce audit-ready documentation. Ability to present findings to various levels of management, and including stakeholders, across the organization.

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.

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. 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.

Preferred:

Coding certifications (CPC, CCS) or equivalent knowledge.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information