Diretor de Reivindicações

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Localização: Condado de Mariposa, Califórnia; Condado de Merced, Califórnia; Condado de Monterey, Califórnia; Condado de San Benito, Califórnia; Condado de Santa Cruz, Califórnia

Join Us in Strengthening Care in Our Communities!  Bring your vision and innovation to claims processing and help transform care for over 400,000 neighbors in five counties.

We welcome applicants from across California, with a strong preference for candidates based in our service areas (Santa Cruz, Monterey, Merced, Mariposa, and San Benito Counties). While this role may offer some remote flexibility, we value team members who are familiar with and connected to our local communities.
 
The Alliance is seeking a dynamic Diretor de Reivindicações to lead our claims operations and ensure timely, accurate service for members and providers across Santa Cruz, Monterey, Merced, Mariposa, and San Benito counties. This is a unique opportunity to make an impact locally, helping deliver quality, reliable care to more than 400,000 neighbors in our region. We’re looking for a leader who brings both technical expertise and a passion for service, collaboration, and continuous improvement. 

Be part of a mission-driven organization that values innovation, integrity, and community connection—while building your career in the heart of Central California. 

O CANDIDATO IDEAL

• A forward-thinking leader who is excited to bring innovative solutions to age-old challenges like inventory backlogs and lean staffing 
• Proven ability to champion change initiatives by effectively communicating the vision, fostering buy-in, and motivating others to embrace new processes and ways of working
• Deep knowledge of claims regulations, policies, and systems, with the ability to translate complex requirements into efficient workflows
• Strategic thinker who can align claims management processes with organizational goals and regulatory requirements
• Experienced in building, coaching, and motivating high-performing teams while fostering accountability and collaboration
• Demonstrates high emotional intelligence, fostering positive relationships with team members, providers, and business partners
• Data-driven leader skilled in using metrics and analytics to monitor performance, identify trends, and implement improvements
• Proactive problem-solver who can navigate ambiguity, resolve escalated issues, and make sound decisions under pressure

WHAT YOU'LL BE RESPONSIBLE FOR:

Reportando-se ao Diretor de Operações, esta posição: 

• Provides strategic management oversight in implementing, directing, and monitoring the Alliance’s Claims Department functions, including the development and implementation of new programs and services related to claims operations
• Directs and oversees the Claims Department, acts as a subject matter expert, and provides direction and advice related to Claims Department functions and overall business operations
• Directs, manages, and supervises Claims Department staff

O QUE VOCÊ PRECISA PARA TER SUCESSO

Para ler a descrição completa do cargo e a lista de requisitos, Clique aqui. 

• Knowledge of, and proficiency in:
• The principles and practices of claims operations and the claims function in a managed care environment
• Promover e aplicar princípios de gestão de mudanças
• Métodos de pesquisa, análise e relatórios
• California Medi-Cal program, Medicaid, Medicare, entitlement programs, and related regulations
• Healthcare regulatory processes and regulatory and contractual compliance activities
• Capacidade de:
  • Direct, manage, supervise, mentor, train, and evaluate the work of staff
  • Develop, plan, organize, and direct programs and activities that are complex in nature and regional in scope
  • Fornecer liderança, facilitar reuniões e fazer parcerias e orientar gerentes e funcionários na resolução de problemas
  • Demonstrar fortes habilidades analíticas, coletar, gerenciar e analisar dados com precisão, identificar problemas, oferecer recomendações e consequências potenciais e mitigar riscos
  • Assess departmental operations, identify opportunities for improvement, and advance operational effectiveness
• Educação e experiência:
  • Bachelor’s degree in Finance, Business Administration, or a related field
  • A minimum of ten years of claims operations experience in a managed care environment, which included some experience with financial management, a minimum of three years of experience working with Medicare and Medi-Cal Programs, and a minimum of five years of management-level experience (a Master’s degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying

OUTRAS INFORMAÇÕES

• We are in a hybrid work environment, and we anticipate that the interview process will take place remotely via Microsoft Teams
• While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected
• In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process

A faixa de remuneração completa para esta posição está listada por local abaixo. 

A remuneração real para esta função será determinada pela nossa filosofia de remuneração, análise das qualificações do candidato selecionado (experiência direta ou transferível relacionada ao cargo, educação ou treinamento), bem como outros fatores (equidade interna, fatores de mercado e localização geográfica).

Áreas típicas na Zona 1: Bay Area, Sacramento, área de Los Angeles, área de San Diego

Áreas típicas na Zona 2: área de Fresno, Bakersfield, Vale Central (com exceção de Sacramento), Califórnia Oriental, área de Eureka

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