Buscar empleo: 104 ofertas de trabajo de direct support en Modesto, California (febrero 2026)

Director, Claims

hace 27 días

Modesto

Job Description The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. The Health Plan of San Joaquin is now hiring an experienced and dedicated Director, Claims! Location: We are looking for someone who lives in our service area. (Must reside in California.) Remote: This is a remote position; however, must be able to attend monthly onsite meetings, and as needed for business and community purposes. What You Will Be Doing: Under limited supervision, the Director of Claims is responsible for developing and overseeing the implementation of strategic and operational objectives and plans consistent with internal and external requirements, best practices, and HPSJ strategies and objectives. Work is varied and complex and requires a high degree of discretion and independent judgment. Supervises Claims Managers Claims Analyst Our Vision: Continuously improve the health of our community. Our Mission: We provide healthcare value and advance wellness through community partnerships. Essential Functions: • Identifies, develops, plans and executes business strategies, collaborating with executives, peers and others to ensure effective integration; directs the development and implementation of department goals and actions plans, • Oversee routine and ad hoc internal and external audits and direct the development, implementation and monitoring of corrective action plans, • Develops and monitors quantitative and qualitative analyses of claims data, trends and forecasting; implements appropriate interventions, • Oversees preparation for and participate in regulatory audits and external review activities; develops and monitors corrective actions plans, • Develops or directs the development of policies; ensures the development and implementation of appropriate companion procedures, guidelines and other documents., • Proactively Identifies and develops strategies to address issues and trends with claims processing, • Ensure compliance with applicable laws and regulations, • Oversee the development, implementation and maintenance of the appropriate and required data, records, reports and other documentation, • Identifies and oversees the implementation of process improvement strategies, • Leads the development, implementation and maintenance of best practice methodology, including metrics; ensures dissemination and understanding among stakeholders, • Anticipates technology needs; oversees development and implementation; collaborates to improve or upgrade current technology solutions, • Develops and manages department budget, implements appropriate interventions, • Promote and maintains and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission and values, • Other duties as required. What You Bring: Knowledge, Skills, Abilities and Competencies Required • Expert knowledge of and ability to apply and facilitate the adoption of best practices., • In-depth knowledge of the principles and practices of claims operations., • In-depth knowledge of health plan functions and interactions and their impact on claims., • In-depth knowledge of regulations and procedures governing Medi-Cal and other state sponsored programs as they relate to claims., • In-depth knowledge of procedure coding and medical terminology, and their application in benefits; general medical policy benefits and exclusions, and industry standard payment practices., • In-depth knowledge of claims processing systems., • Financial acumen: Interprets and applies understanding of key financial indicators to make better business decisions., • Manages complexity: Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems., • Decision quality: Makes good and timely decisions that keep the organization moving forward., • Strategic mindset: Sees ahead to future possibilities and translates them into breakthrough strategies., • Strong knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results., • Ability to create relevant department objectives, and create, execute and monitor business plans., • In-depth knowledge of internal and external audit processes, and the ability to effectively implement and maintain them., • Demonstrated ability to develop and manage realistic budgets., • Strong oral and written communication skills with the ability to communicate professionally, effectively and persuasively to diverse individuals inside and outside of the HPSJ., • Strong interpersonal skills with the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside of HPSJ, • Strong collaboration skills with demonstrated ability to create and foster a collaborative work environment, and maintain effective, high-performance teams., • Strong assessment and analytical skills, including the ability to synthesize, distill concepts, draw conclusions and identify implications., • Build networks: Effectively build formal and informal relationship networks inside and outside of the organization., • Organizational savvy: Maneuvers comfortably through complex policy, process and people-related organizational dynamics., • Persuades: Uses compelling arguments to gain the support and commitment of others., • Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities., • Plans and aligns: Plans and prioritizes work for self and others to meet commitments aligned with organization goals., • Ensures accountability: Holds self and others accountable to meet commitments., • Drives results: Consistently achieve results, even under tough circumstances., • Strong project management skills, including the ability to manage organizational-wide projects to successful conclusions., • Manages ambiguity: Operates effectively, even when things are not certain, or the way forward is not clear., • Strong knowledge of change management theory, with ability to anticipate and implement effectively., • Strong customer service skills., • Promotes and maintains and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission and values., • Ability to supervise staff in a manner that maximizes employee performance and business results, which includes very strong coaching/counseling skills and ability to function as a mentor., • Ability to speak and be understood in English., • In-depth knowledge of QNXT core processing system. What You Have: Education and Experience Required • Bachelor’s Degree or related fields or equivalent experience; and, • At least four years as a manager in a health plan overseeing all aspects of claims administration; and, • At least six years Medi-Cal claims experience; and, • Master’s degree. Licenses, Certifications Required • Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability. What You Will Get: HPSJ Perks: • Competitive salary, • Robust and affordable health/dental/vision with choices in providers, • Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays), • CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan, • Two flexible spending accounts (FSAs), • Employer-Paid Term Life and AD&D Insurance, • Employer-Paid Disability Insurance, • Employer-Paid Life Assistance Program, • Health Advocacy, • Supplemental medical, legal, identity theft protection, • Access to exclusive discount mall, • Education and training reimbursement in addition to employer-paid elective learning courses., • A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do., • A shorter commute – if you’re commuting from the Central Valley to the Bay Area., • Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects. Physical Demands Frequent sitting, standing and walking, constant repetitive motion, frequent talking and listening, occasional handling of materials up to 50 lbs., closeup and distance vision requirements, occasional travel. We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation, and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit. HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics or is associated with anyone who has or is perceived to have these characteristics. Important Notice: This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.

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