Senior Manager, Claims Administration

Job Summary

The Senior Manager, Claims Administration provides daily operational leadership for enterprise claims adjudication across all lines of business. This position is responsible for ensuring timely, accurate, compliant claim processing through disciplined production management, strong operational controls, and consistent application of claims policies, benefit rules, and contractual requirements.

The Senior Manager manages a team to deliver predictable throughput, high first-pass accuracy, strong auto-adjudication rates, and consistent cycle-time performance. The position ensures operational readiness for benefit changes, system updates, regulatory modifications, and cross-functional dependencies while continuously improving process quality and reducing rework. The Senior Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.  Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.  Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.

This position serves as a subject matter expert in claims adjudication logic, benefit structures, regulatory requirements, billing and coding standards, and provider contract application. The Senior Manager builds a high-performing culture grounded in accuracy, accountability, standardization, continuous improvement, and service excellence.

Duties

Oversees the daily mechanics of claims production and ensures a controlled, disciplined, and highly reliable operational environment. Responsible for translating enterprise expectations into consistent frontline execution, maintaining a strong control environment, identifying emerging risks quickly, and building upstream partnerships that drive long-term operational maturity. Ensures claims operations are stable, predictable, and aligned to organizational goals.

Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities. Oversees day-to-day adjudication operations, ensuring a controlled, disciplined, and exceptionally reliable operational environment that is timely, accurate, and high-quality output by L.A. Care staff and external vendors, as necessary. Manages staff to consistently meet or exceed productivity, quality, and inventory performance targets.

Ensures all claims are processed within Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), Covered California and contractual turnaround requirements.

Establishes clear routing, triage, and prioritization models to balance workloads and avoid bottlenecks. Promotes operational discipline around standard operating procedures, configuration updates, and quality checkpoints.

Monitors daily, weekly, and monthly inventory at the claim, queue, and examiner level to anticipate risk and maintain a stable production environment.

Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/ or executive management to define, prioritize, and develop projects and programs. Conducts structured production meetings with staff to review performance trends, quality indicators, and backlog prevention plans.

Identifies systemic constraints and drives timely mitigation through collaboration with cross-functional departments and stakeholders.

Oversees planning and execution during peak periods (open enrollment, benefit year-end/start, provider contract updates).

Partners with cross-functional departments to monitor and improve first-pass accuracy and aims to remove rework. Ensures examiners correctly apply benefits, coding, pricing, and provider contract terms.

Identifies claim types or provider groups with chronic accuracy issues and drives upstream corrections.

Manages initiatives to improve auto-adjudication rates through system corrections, routing refinement, and reduction of manual touchpoints. Ensures examiners receive timely, accurate updates on benefit changes, pricing methods, and new rules.

Acts as a critical operational partner to Configuration and Information Technology (I.T.) for system updates, benefit loads, provider contract implementations, and code-set changes. Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.

Participates in User Acceptance Testing (UAT) planning, test case development, operational validation, and go-live readiness for system changes affecting claims.

Identifies system behavior issues impacting adjudication and ensures prompt ticket creation, escalation, monitoring, and resolution.

Duties Continued

Ensures examiners receive clear, concise operational guidance tied to configuration updates and policy changes.

Engages with Enrollment & Eligibility to resolve data discrepancies impacting member benefits or provider assignments.

Partners with Provider Network on contract load timing, unclear terms, and pricing interpretation issues.

Coordinates with Utilization Management on authorization-related adjudication issues and utilization policy questions.

Collaborates with Payment Integrity to leverage findings that require upstream claims-processing adjustments.

Aligns closely with the senior leadership to ensure seamless handoffs and minimal rework.

Oversees creation and maintenance of daily production reports, dashboards, and forecasting tools. Uses data to analyze examiner performance, inventory patterns, quality trends, and root-cause drivers of errors. Uses analytical insights to develop operational plans that reduce cycle time, rework, and cost.

Provides executive-level reporting on throughput, quality, aging, inventory at risk, and operational health.

Ensures standard operating procedures (SOPs), desktop procedures, workflows, training materials, and job aids are current, accurate, and consistently used across the operation.

Creates feedback loops with cross-functional departments to update procedures based on new rules or system changes. Ensures staff have clarity on benefit interpretation, contract logic, bundling/unbundling rules, and pricing methodologies.

Manages staff and the day-to-day activities in the department. Participates in the department budgeting process. Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team. Responsible for overseeing and managing the budgets of their respective departments Builds a culture of rigor, transparency, analytical curiosity, proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.

Perform other duties as assigned.

Education Required

Education Preferred

Experience

Required:

At least 6 years of experience working in claims operations, provider disputes, adjustments, or related operational functions.

At least 5 years of experience in leading, supervising and or managing staff.

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

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

Experience handling complex claim review, root-cause evaluation, adhering to regulatory TAT requirements, and ensuring accuracy.

Experience working with Coordination of Benefits (COB) and Third-Party Liability (TPL) claims in a managed care setting.

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

Preferred:

Experience supporting regulatory audits, legal reviews, or corrective action plans.

Skills

Required:

Strong knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD)-10, DRG/ Ambulatory Payment Classification (APC), and pricing methodologies.

Strong understanding of adjudication, coding, pricing, the application of Division of Financial Responsibility (DOFR) to claims processing, and managed care payment rules.

An advanced knowledge of contractual pricing mechanisms for inpatient, outpatient, Long Term Care (LTC) and ancillary services.

Knowledge of relevant regulatory requirements (DMHC, DHCS, CMS).

Exceptional written and verbal communication skills, including executive communication.

Strong analytical and decision-making skills for complex claim scenarios.

Ability to provide reporting requirements based on processes and/or regulatory requirements.

Proven problem-solving skills and ability to translate knowledge to the department.

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

Strong attention to detail and ability to manage multiple priorities and tight deadlines.

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