Join Us in Empowering Health Care Across Our Communities! Bring your vision and creativity to our claims processing as we strive to transform care for over 400,000 individuals in our service area. We encourage applications from across California, especially from candidates familiar with our communities. This position offers some remote work flexibility, but we value team members who are connected to our local areas. We are looking for an energetic and results-oriented Director of Claims Operations to lead our claims management team, ensuring timely and accurate services for both members and providers. This is an exceptional opportunity to create a positive impact locally, promoting quality care in regions we serve. The ideal candidate will combine technical proficiency with a dedication to service, teamwork, and continuous enhancement. Join a mission-driven organization that embraces innovation, integrity, and community engagement, while developing your career in the vibrant Central California region. THE IDEAL CANDIDATE WILL HAVE: A visionary mindset with a readiness to introduce innovative solutions to ongoing issues such as inventory backlogs and workforce limitations. Proven capability to lead change initiatives through effective communication, garnering support, and motivating individuals to adopt new processes and methodologies. Thorough understanding of claims regulations and policies, with the ability to convert complex requirements into streamlined workflows. A strategic approach to align claims management with organizational aims and compliance standards. Strong experience in building, coaching, and inspiring high-performing teams, emphasizing accountability and collaboration. High emotional intelligence, nurturing positive relationships with team members, providers, and partners. A data-oriented mindset, adept at utilizing metrics and analytics to assess performance, uncover trends, and initiate enhancements. A proactive approach to problem-solving, capable of navigating uncertainties, resolving escalated challenges, and making informed decisions under pressure. KEY RESPONSIBILITIES INCLUDE: Providing strategic management oversight in executing, directing, and monitoring the claims department's functions while developing and implementing new programs related to claims operations. Directing and supervising the claims department, acting as a subject matter expert, and offering guidance on claims functions and overall business operations. Managing and leading the claims department staff, ensuring high performance and professional development. TO BE SUCCESSFUL, YOU WILL NEED: Knowledge and proficiency in: The principles and practices of claims operations within managed care. Change management principles. Research, analysis, and reporting methodologies. California Medi-Cal and Medicaid programs, Medicare, entitlement programs, and their related regulations. Healthcare regulatory practices and compliance activities.

Ability to: Lead, manage, mentor, train, and evaluate staff effectiveness. Create and direct complex programs and activities on a regional scale. Facilitate teamwork and guide managers and employees in resolving issues. Demonstrate strong analytical skills to collect, manage, and analyze data, identifying solutions and mitigating risks. Assess departmental operations and enhance operational effectiveness.

Education and Experience: Bachelor's degree in Finance, Business Administration, or a related field. At least ten years of claims operations experience in a managed care setting, with minimum experience in financial management, and at least three years in Medicare and Medi-Cal Programs, plus five years at a management level. A Master's degree may count for two years of experience.

OTHER INFORMATION: This role operates in a hybrid work environment, with remote interviews conducted via Microsoft Teams. While some staff may work fully remotely, participation in quarterly company-wide events or department meetings is expected. Some positions may require in-office or community presence as needed by business operations, details discussed during the interview. The full compensation range for this position will be determined by our compensation philosophy and analysis of qualifications, including experience and education. Details are as follows: Zone 1 (Monterey, San Benito, and Santa Cruz): $163,470-$261,560 USD Zone 2 (Mariposa and Merced): $148,756-$238,014 USD OUR BENEFITS Medical, Dental, and Vision Plans. Generous Paid Time Off. 12 Paid Holidays annually. 401(a) and 457 Deferred Compensation Plans. Comprehensive Health and Wellness Program. Onsite EV Charging Stations. ABOUT US: We are a team of over 500 dedicated employees committed to providing accessible, high-quality healthcare driven by local innovation. We take pride in knowing our work positively impacts the community. At Central California Alliance for Health, you’ll be part of a respectful, diverse, professional, enjoyable culture where you'll be empowered to excel. As a regional non-profit health plan, we serve members across various counties. To learn more about our organization, refer to our Fact Sheet. The Alliance is an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender identity, national origin, age, marital status, protected veteran status, or disability status. We participate in E-Verify. Please note that the Alliance does not provide sponsorship at this time. Applicants must be authorized to work in the U.S. on a full-time, ongoing basis without sponsorship needs.