Designs and oversees the claims QA audit methodology, including sampling standards, audit frequency, scoring tools, examiner scorecards, and quality thresholds. Co-leads claims components of mock audits for regulatory agencies, and related review bodies. Prepares audit universes, conducts sample reviews, organizes evidence, and ensures accuracy of documentation for internal/external audits. Ensures QA processes meet expectations for regulatory audit readiness.

Conducts root-cause analysis on quality findings to identify systemic drivers behind defects or inconsistencies. Works with cross functional key stakeholders to implement and validate corrective actions. Confirms that corrective actions address underlying issues and reduce recurrence. Tracks error trending to identify early signals of operational or regulatory risk.

Maintains claims QA guidelines, audit manuals, sampling methodologies, scoring rules, and documentation requirements. Develops quality dashboards, trend analyses, and quality scorecards for Core Administrative Operations leadership. Ensures quality results are communicated clearly, consistently, and with actionable recommendations. Monitors adherence to quality standards across examiners, analysts, and adjustment staff.Duties Continued Partners with Claims Administration to align QA results with workflow changes, training needs, and performance expectations. Coordinates with Configuration’s system QA team to align operational audit insights with system testing requirements (no ownership of configuration QA). Works with Payment Integrity to validate accuracy of post-pay adjustments and ensure systemic issues are fed into preventive controls. Collaborates with Compliance & Training to ensure QA findings inform training content, SOP updates, and policy interpretation. Supports SVU and the Tiger Team by validating accuracy of complex claim reviews and identifying upstream contributors to identified issues.

Establishes performance metrics, audit schedules, and competency expectations. Builds a culture grounded in analytical precision, data integrity, critical thinking, and investigative rigor.  Capitalizes on metrics for proactive indicators of risks, issue identification, cross-functional communication, accountability, transparency, and execute continuous operational improvement.

Manage staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.

Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Responsible for reporting, budgeting, and policy implementation.

Perform other duties as assigned.Education Required

Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.Education Preferred Master's Degree in Business Administration or Related FieldExperience Required

• At least 5 years of experience claims operations, claims auditing, claims QA, or complex claims operational functions.

At least 3 years of experience leading, supervising /managing staff.

Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.

Experience leading teams, projects, initiatives, or cross-functional groups. Experience in Medicaid, Medicare, and Commercial managed care lines of business.

Hands-on experience conducting claims testing or accuracy audits.

Deep experience interpreting provider contracts, payment methodologies, and managed care benefit structures. Demonstrated experience with high complexity claims review and RCA.

Experience supporting or preparing for regulatory audits (DMHC, DHCS, CMS).

Demonstrated experience analyzing claims defects and validating corrective actions.

Preferred

• Coding experience or equivalent knowledge.

Experience partnering with system configuration teams.

Experience with quality program design and audit governance.Skills

Required

• Deep understanding of standard claims processing systems and claims data analysis. Extensive understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing. Deep knowledge of claims adjudication, benefit structures, provider contracting, DoFR, pricing rules, and coding standards. Advanced knowledge of contractual pricing mechanisms for inpatient, outpatient, Long Term Care (LTC) and ancillary services.
• Advanced analytical and root-cause analysis skills. Deep knowledge of relevant regulatory requirements. Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously; strong attention to detail. Ability to track and trend the metrics associated with auditor production. Proficient of Microsoft Office suite, including Word, Excel, Teams and PowerPoint. Highly collaborative and maintain a consultative style with ability to establish credibility quickly with all levels of management across multiple functional areas. Exceptional interpersonal, verbal, and written communication skills, including executive communication with ability to produce audit-ready documentation. Ability to present findings to various levels of management, and including stakeholders, across the organization.
• Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members. Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision. Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.
• Deep understanding of financial principles. Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation. Ability to make informed decisions. Strong verbal, written communication and presentation skills. Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges. Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.

Preferred

• Coding certifications (CPC, CCS) or equivalent knowledge.Licenses/Certifications Required Licenses/Certifications Preferred Certified Professional Coder (CPC) or other equivalent Coding CertificationRequired Training Physical Requirements LightAdditional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.  The range is subject to change.

L. A. Care offers a wide range of benefits including

Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)