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Director of Claims, Redding, CA

Partnership HealthPlan of California


Redding, CA

July 10, 2017

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POSITION TITLE: Director of Claims


To oversee the strategic direction and operational effectiveness and efficiency of all activities of the Claims and Customer Service Departments, including but not limited to claims processing, payment functions, call center management, provider claims education, reporting, and budget. Leads, influences, and transforms a culture of professionalism that will ensure customer satisfaction in keeping with the mission of PHC.


  • Leads, directs, and oversees day-to-day operations and strategic objectives of the Claims department.
  • Develops and implements Claims department strategies, policies, and procedures to ensure department units are in compliance with Federal, State, and regulatory requirements.
  • Assists in Regulatory Audits in addition to any Regulatory reporting requirements as necessary for the Northern Region.
  • Oversees Claims quality control and audit process. Ensures development, implementation, and continual review of audit and quality control processes. Maintains at least 97% accuracy for claims processing.
  • Ensures provider calls are handled in an efficient and professional manner, maintaining call quality of at least 97%.
  • Works collaboratively with IT and Configuration to oversee Claims system configuration and related projects, research, testing, and implementation of system changes.
  • Works with providers to resolve claims billing issues, and coordinates Claims related education for providers and other departments.
  • Reviews and approves high dollar claims, special exceptions, appeals, and claims adjustments.
  • Provides key information to senior management to minimize financial risks of provider contracts on directly contracted product lines and regulatory issues affecting claims administration.
  • Leads project management and implementation as well as oversight of department goals and initiatives.
  • Other duties as assigned.


Education and Experience

Four year college degree; minimum five (5) years senior level management experience in an automated claims environment; or equivalent combination of education and experience.

Special Skills, Licenses and Certifications

Strong public speaking and presentation skills. Strong strategic thinking and business planning skills with the ability to develop clear business plans aligned with business strategy. Provide vision, leadership, and oversight to specific teams. Excellent analytical and problem solving skills and an ability to exercise professional judgement and assume responsibility for decisions which have an impact on people, costs, and quality of service. Excellent knowledge of Medi-Cal regulations, CPT, and ICD-10 coding, reimbursement methods, and claims processing, policies, and procedures. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.

Performance Based Competencies

Demonstrate excellent leadership skills with the ability to establish, and motivate staff to achieve goals and objectives. Excellent interpersonal skills to ensure effective operations, meeting deadlines and accuracy standards. Excellent written and oral communications skills.

Work Environment And Physical Demands

More than 50% of work time is spent in front of a computer monitor; when required, the ability to life, carry, or move objects of varying size, weighing up to 25 lbs. Must be able to work in a fast-paced environment and maintain courtesy and composure when dealing with internal and external customers. Ability to function effectively with frequent interruptions and direction from multiple team members.

All HealthPlan employees are expected to:

  • Provide the highest possible level of service to clients;
  • Promote teamwork and cooperative effort among employees;
  • Maintain safe practices; and
  • Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.


The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

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