Director/Sr. Director - Claims

Department: Ops - Claims OpsLocation: 1600 Corporate Center Dr., Monterey Park, CA 91754Compensation: $150,000 - $180,000 / yearDescriptionThe Director - Claims will be responsible for overseeing the end-to-end claims management process, ensuring accuracy, efficiency, and compliance with regulatory standards. This role involves leading a team of claims professionals, optimizing workflows, and driving strategic initiatives to improve claims operations. The ideal candidate is an experienced leader with a deep understanding of healthcare claims, payer-provider relationships, and a commitment to delivering exceptional service.Our Values:Put Patients FirstEmpower Entrepreneurial Provider and Care TeamsOperate with Integrity & ExcellenceBe InnovativeWork As One TeamWhat You'll DoLeadership & StrategyProvide strategic direction for the claims department, aligning operations with company goals and regulatory requirementsLead, mentor, and develop a high-performing claims management teamCollaborate with executive leadership to establish and achieve claims-related KPIs and financial targetsIdentify the root cause of any operational weaknesses and implement the best solutionServe as a thought partner to internal and external stakeholders to achieve mutual goalsClaims Management OperationsOversee end-to-end claims operations, claims processing, adjudication, and resolution to ensure timeliness, accuracy, and complianceDevelop, implement, review dashboards, reports, policies, procedures, and workflows to optimize efficiency and mitigate errorsTeam accountability for areas such as – timeliness reporting to the health plans, encounter reports, weekly inventory and workflow reports, and IPA claims summary report for board meetingsMonitor and address claim denial trends, providing actionable insights and corrective strategiesManage relationships with payers, third-party administrators, and other key stakeholdersCompliance & ReportingEnsure compliance with state, federal, and industry regulations, including HIPAA and CMS guidelinesPrepare and present regular reports on claims performance, trends, and department metricsConduct audits and reviews to maintain high standards of accuracy and complianceQualificationsBachelor’s degree in healthcare administration, business, or a related field8+ years of progressive responsibility, preferably in a managed care setting Knowledge of DMHC, DHS, and CMS regulations and guidelines Proficient in knowledge of CPT, HCPCS, ICD-10, Strong knowledge of MSO operations, healthcare reimbursement models, and payer/provider dynamicsExpertise in claims processing systems and technologies (e.g., EHR, claims adjudication software) In-depth understanding of healthcare regulations, including HIPAA and CMS guidelinesPrior experience working in managed care/IPA settingYou're great for the role if:You have a master's degreeHave EZ-CAP software experienceEnvironmental Job Requirements and Working ConditionsOur organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Dr., Monterey Park, CA 91754.The national target pay range for this role is $150,000 - $180,000. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation. Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.