The Role
The Senior Claims Manager oversees Claims Delegation Audits, ensures compliance with regulations, develops audit strategies, manages corrective actions, collaborates cross-functionally, and leads a performance-driven team.
Summary Generated by Built In
The Senior Claims Manager, Claims Delegation Oversight, is responsible for the management and oversight of all Claims Delegation Audits, including health plan and governing agencies audits, i.e., DMHC, CMS, and DHCS. This role will be responsible for the development and execution of department strategies, overall Audit program, Audit process optimization, and management, identifying and leveraging technology and data to improve the quality and minimizing process cost of Claims. The position alongside the leadership team will contribute to driving strategic planning, operational excellence, and accuracy of the claims process and ensure compliance with regulations and contract requirements for Medicare, Commercial Exchange, and Medicaid service lines.
Our Values:
Our Values:
- Put Patients First
- Empower Entrepreneurial Provider and Care Teams
- Operate with Integrity & Excellence
- Be Innovative
- Work As One Team
What You'll Do
External Audit planning, execution & support
- Own the end‑to‑end strategy and execution of all external audits (e.g., CMS, DMHC, health plan audits), ensuring readiness, successful delivery, and continuous score improvement
- Lead audit planning, pre‑audit readiness reviews, execution, issue tracking, and final reporting
- Establish and monitor audit metrics, scorecards, and dashboards; ensure timely, accurate communication of results
- Oversee corrective action plan (CAP) management, including root cause analysis, remediation, and prevention strategies
- Partner with Claims Operations to ensure audit findings are remediated promptly and sustainably
Documentation, Compliance & Training
- Review and approve audit‑related policies, procedures, workflows, job aids, and SOPs for accuracy and regulatory compliance
- Ensure adherence to all legislative, regulatory, and contractual requirements
- Identify training gaps, oversee training strategy and delivery, and measure training effectiveness
Cross‑Functional Collaboration & Process Improvement
- Collaborate closely with internal partners (Claims, UM, CM, Pharmacy, Compliance, IT, Finance, Configuration, Network, and others) to resolve issues and drive operational excellence
- Partner with IT and Data Analytics to develop and maintain audit tools, reports, dashboards, and scorecards
- Recommend and support system, rules, and workflow improvements impacting claims adjudication and audit outcomes
- Lead or support special projects, including new business implementations, business analyses, and strategic initiatives
People Leadership
- Set team goals, define success metrics, and drive accountability
- Recruit, develop, coach, and motivate a high‑performing team
- Track performance and guide the team to achieve audit and operational objectives
Other duties as assigned
Qualifications
- Bachelor’s degree (BA/BS) or equivalent combination of education and experience
- 3+ years of claims administration experience within a Health Plan, IPA, or MSO environment
- 3+ years of experience supporting or overseeing health plan and delegation audits
- 3+ years of people leadership experience, including coaching and performance management
- Hands‑on claims auditing experience, including root cause analysis and corrective action management
- Have advanced knowledge of CMS, DHCS, DMHC, Medicare, Medi‑Cal, and Medicaid regulations impacting claims adjudication
- Strong understanding of claims payment methodologies (e.g., RBRVS, DRG/AP‑DRG, APC, Medicare/Medi‑Cal fee schedules)
- Proficiency in Excel, including creating and maintaining reports and data summaries
- Highly organized, adaptable, and able to prioritize in a fast‑paced environment with minimal supervision
- Proven ability to lead, coach, and motivate teams toward defined performance goals
- Strong analytical, problem‑solving, and decision‑making skills
You’re great for the role if
- Master's Degree
- Have experience with claims systems and tools (e.g., EzCap, IDX, Cotiviti, Burgess)
- Familiarity with clearinghouses (e.g., Office Ally), core system implementation, and configuration
Environmental Job Requirements and Working Conditions
- Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis if you live within 35 miles. The office is located at 1600 Corporate Center Dr. Monterey Park, CA 91754.
- The national target pay range for this role is $125,000 - $140,000. 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 [email protected] 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.
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.
About
Astrana Health (NASDAQ: ASTH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient. Our platform currently empowers over 20,000 physicians to provide care for over 1.7 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.
Skills Required
- Bachelor's degree (BA/BS) or equivalent education and experience
- 3+ years of claims administration experience within a Health Plan, IPA, or MSO environment
- 3+ years of experience supporting or overseeing health plan and delegation audits
- 3+ years of people leadership experience, including coaching and performance management
- Hands‑on claims auditing experience, including root cause analysis and corrective action management
- Advanced knowledge of CMS, DHCS, DMHC, Medicare, Medi‑Cal, and Medicaid regulations
- Strong understanding of claims payment methodologies
- Proficiency in Excel, including creating and maintaining reports and data summaries
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The Company
What We Do
Astrana Health is a physician-centric, technology-powered healthcare company that operates an integrated delivery platform. It enables providers to participate in value-based care arrangements, helping them deliver accessible, high-quality, and cost-effective care to patients. The company provides care coordination services to patients, primary care physicians, specialists, and health plans, leveraging proprietary technology to streamline operations and improve patient outcomes across local communities.
