Claims Manager

JOB SUMMARY:

The Claims Manager is responsible for overseeing the daily operations, performance, and regulatory compliance of the Claims Department within the Managed Services Organization (MSO). This role provides leadership and supervision to Claims Examiners and ensures the accurate, timely, and compliant adjudication of professional and institutional claims in accordance with health plan contracts, regulatory requirements, and organizational policies.

The Claims Manager monitors claims inventory, production, and quality metrics, ensures adherence to turnaround time standards, and supports operational efficiency and compliance with federal and California regulatory requirements, including Department of Managed Health Care (DMHC), Centers for Medicare & Medicaid Services (CMS), and Department of Health Care Services (DHCS) requirements where applicable.

This position plays a critical role in ensuring claims processing accuracy, maintaining provider satisfaction, protecting organizational financial integrity, and supporting delegated managed care operations.