Central California Alliance for Health
Claims Director
Central California Alliance for Health, California, Missouri, United States, 65018
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 Claims Director 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. Were 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 connectionwhile building your career in the heart of Central California. THE IDEAL CANDIDATE 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
Reporting to the Chief Operating Officer, this position: Provides strategic management oversight in implementing, directing, and monitoring the Alliances 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 WHAT YOU'LL NEED TO BE SUCCESSFUL To read the full position description and list of requirements, click here . Knowledge of, and proficiency in: The principles and practices of claims operations and the claims function in a managed care environment Promoting and applying change management principles Research, analysis, and reporting methods California Medi-Cal program, Medicaid, Medicare, entitlement programs, and related regulations Healthcare regulatory processes and regulatory and contractual compliance activities Ability to:
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 Provide leadership, facilitate meetings, and partner with and guide managers and employees in the resolution of issues Demonstrate strong analytical skills, accurately collect, manage, and analyze data, identify issues, offer recommendations and potential consequences, and mitigate risk Assess departmental operations, identify opportunities for improvement, and advance operational effectiveness
Education and Experience:
Bachelors 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 Masters degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying
OTHER INFORMATION 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 The full compensation range for this position is listed by location below.
The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location). Typical areas in Zone 1: Bay Area, Sacramento, Los Angeles area, San Diego area Typical areas in Zone 2: Fresno area, Bakersfield, Central Valley (with the exception of Sacramento), Eastern California, Eureka area Zone 1 (Monterey, San Benito and Santa Cruz) We are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us. The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender perception or identity, national origin, age, marital status, protected veteran status, or disability status. We are an E-Verify participating employer Join us at Central California Alliance for Health (the Alliance) is an award-winning regional Medi-Cal managed care plan that provides health insurance for children, adults, seniors and people with disabilities in Mariposa, Merced, San Benito and Santa Cruz counties. We currently serve more than 418,000 members. To learn more about us, take a look at our Fact Sheet
. At this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship. Create a Job Alert Interested in building your career at Central California Alliance for Health (Remote)? Get future opportunities sent straight to your email. Apply for this job
* indicates a required field First Name * Last Name * Email * Phone * Resume/CV * Enter manually Accepted file types: pdf, doc, docx, txt, rtf Enter manually Accepted file types: pdf, doc, docx, txt, rtf Are you a current or former employee of any of the following state agencies? Department of Health Care Services (DHCS), California Department of Social Services (DSS), or Department of Managed Health Care (DMHC)? If yes, please select below. * No Yes - Department of Health Care Services (DHCS) Yes - California Department of Social Services (DSS) Yes - Department of Managed Health Care (DMHC) Current Address * Current City * Current State * Select... Current County in California * Select... If you are not currently in the state of California, do you have plans to relocate? * Select... Will you now or in the future require sponsorship for employment visa status? * Select... This position requires a valid Driver's License, transportation, and automobile liability insurance. Do you meet this requirement? * Select... Are you at least 18 years old? (If under 18, hire is subject to verification that you are ofminimum legal age.) * Select... Are you interested in being contacted about temporary assignments or positions at the Alliance in the future? * Select... In addition to hiring regular positions, like the one that you are applying to, we also have temporary positions available at times. Let us know if you would like to be contacted about these opportunities in the future by selecting 'yes' below. Select... As a reminder, please use the
Employee Careers Portal
to login and submit your application. You can access the link through the Weekly TA Announcement. Are you a former Alliance employee? Select... Are you a current temporary employee on an assignment at the Alliance? Select... Are you a former temporary employee who has been on an assignment at the Alliance? Select... Are you related to a current Alliance Employee? * Select... The Alliance definesrelatives in policy Hiring of Relatives #101-1022 to include: spouse / domestic partner, children, siblings, parents, in-laws, step-relatives, aunts, uncles, nieces, nephews and cousins. This policy also may apply to individualswho are not legally related but who reside with another employee. Relativesshall not directly supervise one another, and/orshall not have any responsibility for monitoring or establishing one anothers performancestandards, and/or have any influence, input, or responsibility for determining one anothers compensation, merit increases or other compensation-related activity. If you are related to a current Alliance Employee, please list their name: I acknowledge the following questions are related to our Employee Recruitment Incentive Program * Select... Did one of our current employees tell you about the Alliance and/or this position? * Select... If yes, you must enter their name in order for them to qualify. Please enter their name here: I hereby certify that the facts and information set forth in my application and resume are true and complete. I authorize Central California Alliance for Health and its agents to investigate any and all of the statements that I have made. I understand that if I supply false or misleading information on my application or resume I may not be considered for employment. I also understand that if I become employed, false statements on this application or resume, or omissions of information may result in my termination. * My typed name shall have the same force and effect as my written signature. U.S. Standard Demographic Questions
The Alliance is dedicated to creating a work environment focusing on inclusivity and belonging, In addition, we are interested in ensuring we have a diverse workforce. To that end, we invite you to voluntarily self-identify your race and ethnicity, as well as provide information on additional demographics. This data will remain anonymous and reported in aggregate to support our Diversity, Equity, Inclusion and Belonging efforts and to improve our future outreach and recruitment efforts. How would you describe your gender identity? (mark all that apply) Select... How would you describe your racial/ethnic background? (mark all that apply) Select... How would you describe your sexual orientation? (mark all that apply) Select... Do you identify as transgender? Select... Do you have a disability or chronic condition (physical, visual, auditory, cognitive, mental, emotional, or other) that substantially limits one or more of your major life activities, including mobility, communication (seeing, hearing, speaking), and learning? Select... Are you a veteran or active member of the United States Armed Forces? Select... #J-18808-Ljbffr
The Alliance is seeking a dynamic Claims Director 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. Were 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 connectionwhile building your career in the heart of Central California. THE IDEAL CANDIDATE 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
Reporting to the Chief Operating Officer, this position: Provides strategic management oversight in implementing, directing, and monitoring the Alliances 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 WHAT YOU'LL NEED TO BE SUCCESSFUL To read the full position description and list of requirements, click here . Knowledge of, and proficiency in: The principles and practices of claims operations and the claims function in a managed care environment Promoting and applying change management principles Research, analysis, and reporting methods California Medi-Cal program, Medicaid, Medicare, entitlement programs, and related regulations Healthcare regulatory processes and regulatory and contractual compliance activities Ability to:
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 Provide leadership, facilitate meetings, and partner with and guide managers and employees in the resolution of issues Demonstrate strong analytical skills, accurately collect, manage, and analyze data, identify issues, offer recommendations and potential consequences, and mitigate risk Assess departmental operations, identify opportunities for improvement, and advance operational effectiveness
Education and Experience:
Bachelors 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 Masters degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying
OTHER INFORMATION 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 The full compensation range for this position is listed by location below.
The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location). Typical areas in Zone 1: Bay Area, Sacramento, Los Angeles area, San Diego area Typical areas in Zone 2: Fresno area, Bakersfield, Central Valley (with the exception of Sacramento), Eastern California, Eureka area Zone 1 (Monterey, San Benito and Santa Cruz) We are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us. The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender perception or identity, national origin, age, marital status, protected veteran status, or disability status. We are an E-Verify participating employer Join us at Central California Alliance for Health (the Alliance) is an award-winning regional Medi-Cal managed care plan that provides health insurance for children, adults, seniors and people with disabilities in Mariposa, Merced, San Benito and Santa Cruz counties. We currently serve more than 418,000 members. To learn more about us, take a look at our Fact Sheet
. At this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship. Create a Job Alert Interested in building your career at Central California Alliance for Health (Remote)? Get future opportunities sent straight to your email. Apply for this job
* indicates a required field First Name * Last Name * Email * Phone * Resume/CV * Enter manually Accepted file types: pdf, doc, docx, txt, rtf Enter manually Accepted file types: pdf, doc, docx, txt, rtf Are you a current or former employee of any of the following state agencies? Department of Health Care Services (DHCS), California Department of Social Services (DSS), or Department of Managed Health Care (DMHC)? If yes, please select below. * No Yes - Department of Health Care Services (DHCS) Yes - California Department of Social Services (DSS) Yes - Department of Managed Health Care (DMHC) Current Address * Current City * Current State * Select... Current County in California * Select... If you are not currently in the state of California, do you have plans to relocate? * Select... Will you now or in the future require sponsorship for employment visa status? * Select... This position requires a valid Driver's License, transportation, and automobile liability insurance. Do you meet this requirement? * Select... Are you at least 18 years old? (If under 18, hire is subject to verification that you are ofminimum legal age.) * Select... Are you interested in being contacted about temporary assignments or positions at the Alliance in the future? * Select... In addition to hiring regular positions, like the one that you are applying to, we also have temporary positions available at times. Let us know if you would like to be contacted about these opportunities in the future by selecting 'yes' below. Select... As a reminder, please use the
Employee Careers Portal
to login and submit your application. You can access the link through the Weekly TA Announcement. Are you a former Alliance employee? Select... Are you a current temporary employee on an assignment at the Alliance? Select... Are you a former temporary employee who has been on an assignment at the Alliance? Select... Are you related to a current Alliance Employee? * Select... The Alliance definesrelatives in policy Hiring of Relatives #101-1022 to include: spouse / domestic partner, children, siblings, parents, in-laws, step-relatives, aunts, uncles, nieces, nephews and cousins. This policy also may apply to individualswho are not legally related but who reside with another employee. Relativesshall not directly supervise one another, and/orshall not have any responsibility for monitoring or establishing one anothers performancestandards, and/or have any influence, input, or responsibility for determining one anothers compensation, merit increases or other compensation-related activity. If you are related to a current Alliance Employee, please list their name: I acknowledge the following questions are related to our Employee Recruitment Incentive Program * Select... Did one of our current employees tell you about the Alliance and/or this position? * Select... If yes, you must enter their name in order for them to qualify. Please enter their name here: I hereby certify that the facts and information set forth in my application and resume are true and complete. I authorize Central California Alliance for Health and its agents to investigate any and all of the statements that I have made. I understand that if I supply false or misleading information on my application or resume I may not be considered for employment. I also understand that if I become employed, false statements on this application or resume, or omissions of information may result in my termination. * My typed name shall have the same force and effect as my written signature. U.S. Standard Demographic Questions
The Alliance is dedicated to creating a work environment focusing on inclusivity and belonging, In addition, we are interested in ensuring we have a diverse workforce. To that end, we invite you to voluntarily self-identify your race and ethnicity, as well as provide information on additional demographics. This data will remain anonymous and reported in aggregate to support our Diversity, Equity, Inclusion and Belonging efforts and to improve our future outreach and recruitment efforts. How would you describe your gender identity? (mark all that apply) Select... How would you describe your racial/ethnic background? (mark all that apply) Select... How would you describe your sexual orientation? (mark all that apply) Select... Do you identify as transgender? Select... Do you have a disability or chronic condition (physical, visual, auditory, cognitive, mental, emotional, or other) that substantially limits one or more of your major life activities, including mobility, communication (seeing, hearing, speaking), and learning? Select... Are you a veteran or active member of the United States Armed Forces? Select... #J-18808-Ljbffr