Senior Manager – Claims Delegation Audit

Role Overview

• 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
• 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
• 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
• 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

Requirements

• 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.

Benefits

• 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.
• Health insurance
• 401(k)
• Paid time off
• Professional development opportunities