Sr. Manager - Claims Delegation Audit

• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Operate with Integrity & Excellence
• Be Innovative
• Work As One Team

What You'll Do

• Own the end‑to‑end strategy and execution of all external audits (e.g., CMS, DMHC, health plan audits), ensuring readiness, successful delivery, and continuous score improvement
• Lead audit planning, pre‑audit readiness reviews, execution, issue tracking, and final reporting
• Establish and monitor audit metrics, scorecards, and dashboards; ensure timely, accurate communication of results
• Oversee corrective action plan (CAP) management, including root cause analysis, remediation, and prevention strategies
• Partner with Claims Operations to ensure audit findings are remediated promptly and sustainably

• Review and approve audit‑related policies, procedures, workflows, job aids, and SOPs for accuracy and regulatory compliance
• Ensure adherence to all legislative, regulatory, and contractual requirements
• Identify training gaps, oversee training strategy and delivery, and measure training effectiveness

• Collaborate closely with internal partners (Claims, UM, CM, Pharmacy, Compliance, IT, Finance, Configuration, Network, and others) to resolve issues and drive operational excellence
• Partner with IT and Data Analytics to develop and maintain audit tools, reports, dashboards, and scorecards
• Recommend and support system, rules, and workflow improvements impacting claims adjudication and audit outcomes
• Lead or support special projects, including new business implementations, business analyses, and strategic initiatives

• Set team goals, define success metrics, and drive accountability
• Recruit, develop, coach, and motivate a high‑performing team
• Track performance and guide the team to achieve audit and operational objectives

Qualifications

• Bachelor’s degree (BA/BS) or equivalent combination of education and experience
• Have at least 3 years of claims administration experience within a Health Plan, IPA, or MSO environment
• Have at least 3 years of experience supporting or overseeing health plan and delegation audits
• Have at least 3 years of people leadership experience, including coaching and performance management
• Hands‑on claims auditing experience, including root cause analysis and corrective action management
• Have advanced knowledge of CMS, DHCS, DMHC, Medicare, Medi‑Cal, and Medicaid regulations impacting claims adjudication
• Strong understanding of claims payment methodologies (e.g., RBRVS, DRG/AP‑DRG, APC, Medicare/Medi‑Cal fee schedules)
• Proficiency in Excel, including creating and maintaining reports and data summaries
• Highly organized, adaptable, and able to prioritize in a fast‑paced environment with minimal supervision
• Proven ability to lead, coach, and motivate teams toward defined performance goals
• Strong analytical, problem‑solving, and decision‑making skills

• Master's Degree
• Have experience with claims systems and tools (e.g., EzCap, IDX, Cotiviti, Burgess)
• Familiarity with clearinghouses (e.g., Office Ally), core system implementation, and configuration

Environmental Job Requirements and Working Conditions

• Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis if you live within 35 miles. The office is located at 1600 Corporate Center Dr. Monterey Park, CA 91754.
• The national target pay range for this role is $125,000 - $140,000. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.