Manager, Claims Research and Remediation

Job Summary

The Manager, Claims Research and Remediation manages L.A. Care’s specialized “Tiger Team” responsible for investigating, reconstructing, quantifying, and remediating the most complex and high-risk claims issues across the enterprise. This includes deep-dive root cause analysis (RCA), litigation-related claims support, systemic defect reconstruction, mass adjustment planning, execution, and large-scale remediation efforts required to mitigate legal, regulatory, or financial exposure. 

The Manager serves as a trusted operational partner to cross-functional key stakeholders by conducting high-precision analyses, validating claim impacts across multiple time periods, creating audit-ready documentation, and designing remediation strategies that reduce risk and recommends quality assurance protocols to ensure accuracy across the claims ecosystem.

The Manager manages and leads staff who research and remediate complex providers, contracts, benefit structures, retroactive policy changes, system defects, and multi-year claim reviews. The position ensures deep analytical rigor, data integrity, quality control, and cross-functional coordination in all remediation work.

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

Duties

Drives L.A. Care’s most critical investigative and corrective work.  Deals with the highest regulatory, financial, or legal exposure. Ensures that investigations are comprehensive, evidence-based, and defensible, and that remediation actions are accurate, auditable, and sustainable. Leveraging analytics, structured project leadership, and strong cross-functional collaboration, protects the organization while strengthening upstream processes and long-term operational reliability.

Leads the investigation of complex issues involving benefit configuration errors, contract misinterpretation, pricing defects, authorization discrepancies, coding anomalies, or systemic system defects. Reconstructs claims outcomes across multiple adjudication cycles, benefit periods, and contract iterations to determine root cause and impact. Conducts multi-layered RCA involving claims rules, configuration tables, provider contracts, Electronic Data Interchange (EDI) inputs, pricing logic, benefit grids, Utilization Management (UM) decisions, and historical system changes. Develops complete audit trails documenting “what happened,” “why it happened,” and “how to prevent recurrence.”

Partners with Legal to support litigation research, discovery preparation, and exposure modeling. Conducts claims sampling, case reconstruction, data pulls, validation, and preparation of evidentiary claim packages. Provides operational insights and documentation required for regulators, external auditors, and legal proceedings. Works with Compliance to design corrective action plans and support enterprise readiness during regulatory reviews, inquiries, or settlements.

Partners with Claims Administration and Quality Assurance (QA) in the development of end-to-end remediation plans, including identification, retrieval, correction, reprocessing, and reconciliation of affected claims. Oversees multi-layered remediation for retroactive benefit changes, contract corrections, reimbursement updates, or operational/system defects. Ensures remediation execution is compliant, accurate, documented, and coordinated with cross-functional key stakeholders. Recommends QA/validation protocols before, during, and after remediation cycles.

Duties Continued

Develops models to quantify regulatory, legal, or financial exposure across multiple scenarios. Validates datasets received from other business units and ensures completeness, accuracy, and audit-readiness. Performs scenario testing to predict downstream implications of proposed changes, settlements, or corrective actions. Partners with Finance on financial projections and reserve-setting guidance.

Works closely with cross-functional key stakeholders to validate findings and ensure remediation is accurate and aligned with operational rules. Identifies upstream gaps uncovered during investigations and partners with business owners to implement preventive controls. Provides recommendations for system enhancements, procedural changes, or policy updates to reduce recurrence of similar issues.

Creates executive-level reports summarizing findings, root causes, risks, and recommended actions. Produces audit-ready documentation for regulators, legal stakeholders, Compliance, and leadership. Maintains strict confidentiality, secure data handling protocols, and precise audit trails.

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. Assigns work, monitors progress, ensures quality, and maintains strong project management discipline. Builds a culture grounded in analytical precision, data integrity, critical thinking, and investigative rigor and supports proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.

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.

Performs other duties as assigned.

Education Required

Education Preferred

Experience

Required:

At least 5 years of experience working in claims research, auditing, payment integrity, provider disputes, adjustments, or complex claims operational functions.

At least 3 years of 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.

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

Demonstrated experience with high complexity claims review and RCA.

Experience interacting with Legal, Compliance, or regulators.

Strong experience with claims system logic, configuration dependencies, provider contracts, and benefit structures.

Preferred:

Experience supporting litigation, corrective action plans, or legal inquiry responses.

Experience with multi-system data validation or complex SQL/data analysis.

Coding experience or equivalent knowledge.

Skills

Required:

Expert-level analytical and investigatory skills. Ability to analyze complex datasets and reconcile conflicting data sources. Exceptional presentation skills, written and verbal communication skills, including executive communication skills with the ability to produce audit-ready documentation. Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing. Strong understanding of pricing methodologies, coding rules, benefit logic, and contract interpretation. Deep knowledge of relevant regulatory requirements (Department of Managed Health Care (DMHC), California Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS)). High proficiency with Excel, SQL, Access, or claims-data tools. Ability to lead cross-functional, high-pressure, confidential initiatives with minimal oversight. Demonstrated ability to make informed decisions. 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. 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:

Ability to review claims in 360-degree approach.

Ability to present findings to various levels of management, and including stakeholders, across all organization.

Coding certifications (CPC, CCS) or equivalent knowledge.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information