Senior Director Revenue Cycle

About The Wilshire Group 

The Wilshire Group, a renowned boutique consulting firm in Los Angeles, specializes in revenue cycle optimization and fostering effective collaboration between operational and IT facets.  With a robust track record of aiding over 100 healthcare systems nationwide, our team thrives on professionalism, efficiency, and adaptability.

Our core values- professionalism, efficiency, and flexibility- underscore our commitment to creating an inclusive and dynamic workplace.  We embrace diverse narratives and believe in offering opportunities to exceptional individuals who bring their best to the table.

We are currently offering a contracted interim position at one of US News Best Hospitals 2022-23.  This position caters to top performers seeking a professional environment that acknowledges and values their dedication and proficiency.  While this role doesn’t offer benefits, it presents an opportunity to work within an organization that encourages talented individuals to surpass conventional boundaries.

Join us at The Wilshire Group, a place where talented professionals find a home to showcase their skills and contribute meaningfully to the healthcare landscape.

Why Wilshire? Employee Testimonial

“The number of RCM subject matter experts I get to work with each day is unreal.  Working alongside and as part of this team to help shape the RCM space is exciting.”-Patti Consolver, Director of Business Development 

This is a contracted position for 6+ months.   Equivalent to $95-$100 per hour.

Job Title: Senior Director, Managed Care Operations
Reports to: Executive Leadership
Location: San Diego, CA (On-Site)

The Senior Director of Managed Care Operations is responsible for the strategic planning, organization, and execution of managed care claims operations for a healthcare system that includes hospitals and affiliated medical groups. This role oversees operations related to managed care enrollment for over 325,000 lives, claims processing, encounter and HCC reporting, contract reimbursement, denial management, business analytics, budgeting, and operational support services.

The position plays a critical leadership role in transforming processes, improving financial performance, and aligning systems to ensure accuracy, efficiency, and compliance. The Senior Director collaborates with cross-functional teams including revenue cycle, legal, compliance, information systems, and health plan partners to ensure effective and integrated operations.

• Directs and oversees managed care claims operations, including claims adjudication, enrollment, and reporting functions.

• Develops and implements operational strategies aligned with organizational goals and regulatory requirements.

• Leads process improvement initiatives to enhance service delivery, reduce costs, and improve performance outcomes.

• Ensures timely and accurate processing of claims and enrollment data.

• Oversees contract reimbursement and denial management processes.

• Manages compliance with industry regulations and internal policies.

• Leads system conversions, upgrades, and technology enhancements related to claims operations.

• Develops and monitors departmental budgets and key financial metrics.

• Reviews financial reports for accuracy, identifies trends, and implements corrective actions.

• Provides executive consultation on financial implications of payer programs and policy changes.

• Maintains up-to-date claims policies and internal controls.

• Ensures compliance with federal, state, and payer requirements.

• Implements remediation plans to address identified compliance gaps.

• Champions the development of new claims and reporting tools to enhance operational performance.

• Prioritizes information system initiatives to support managed care operations.

• Partners with technology teams to drive continuous improvements and data integrity.

• Provides strategic leadership and mentoring to managers and staff.

• Fosters a culture of accountability, performance, and continuous learning.

• Builds strong partnerships with internal and external stakeholders to support organizational success.

Education:

• Bachelor’s degree in Business Administration, Healthcare Administration, Finance, Accounting, or a related field (required).

• Master’s degree (preferred).

Experience:

• Minimum of 10 years of progressive experience in managed care operations, revenue cycle, or healthcare finance.

• Strong background in claims processing, managed care contracting, financial performance management, and team leadership.

• Proven success leading large teams and complex, cross-functional projects in a healthcare setting.

• 5+ Years of Tapestry and Epic (HB, PB) preferred

Skills:

• Deep knowledge of managed care principles, payer relations, and healthcare reimbursement methodologies.

• Deep understanding of Single Business Office (SBO), compliance, and California healthcare laws..

• Demonstrated ability to lead change, drive operational improvements, and manage performance through metrics.

• Strong communication, collaboration, and problem-solving skills.

• Strong leadership skills