[Hiring] Manager, Claims Strategy & Operations Governance @Health Plan of San Joaquin/Mountain Valley Health Plan

Role Description

This is a remote position. Must reside in California, preferably in our service area.

Under general direction, the Manager, Claims Strategy & Operations Governance is responsible for leading and integrating the governance, operational strategy, quality assurance, and recovery functions that support Claims Operations at the enterprise level. The role strengthens accountability, enhances visibility, and improves coordination across claims-related functions, including:

• Claims Operations
• Configuration
• Provider Disputes
• Adjustments
• Recovery
• QA
• Training
• Other functional teams

This position provides direct supervisory oversight of Quality Assurance and Recovery/Payment Integrity, while maintaining dotted-line governance oversight of Claims Operations, Provider Disputes (PDR), Adjustments, Training, and related operational areas. The manager ensures enterprise alignment, supports transformation activities, identifies operational risks, maintains governance infrastructure, and drives readiness for audits, regulatory requirements, and cross-functional initiatives. The work is highly complex and requires independent judgment, strategic thinking, strong communication skills, and an ability to influence across multiple levels without direct authority.

Supervises:

• Supervisors (QA & Recovery)
• Analysts
• Examiners
• Clerks (if aligned under QA or Recovery)

Essential Functions:

• Develops strategic and operational plans that align departmental objectives with enterprise-wide priorities; monitors progress and implements appropriate interventions.
• Establishes and maintains governance infrastructure for Claims Operations and related functions, including meeting cadence, reporting packages, dependency mapping, dashboards, initiative logs, and action item follow-through.
• Provides dotted-line governance oversight of Claims Operations, including performance monitoring, priority alignment, issue escalation tracking, and operational readiness assessment.
• Directly oversees Quality Assurance, including audit processes, quality metrics, error trends, and corrective action plans to support quality and compliance improvements.
• Owns Recovery / Payment Integrity programs, including audit oversight, financial and operational reporting, savings validation, vendor coordination, regulatory compliance, and execution readiness.
• Facilitates alignment across Claims Operations, Configuration, Provider Disputes, Adjustments, Recovery, QA, Training, and other functional partners to ensure cohesive workflow design, coordinated execution, and unified problem-solving.
• Coordinates transformation initiatives across claims-related functions, including workflow redesign, stabilization efforts, reporting modernization, recovery modernization, and operational readiness activities.
• Develops and maintains governance reporting packages, executive summaries, performance dashboards, and initiative tracking documentation to support leadership visibility and decision-making.
• Identifies operational, regulatory, and cross-functional risks; recommends mitigation strategies and supports the implementation of long-term controls.
• Oversees development, implementation, and maintenance of documentation including workflows, procedures, routing rules, governance logs, dependency maps, and operational frameworks.
• Serves as escalation point for complex claims, regulatory, recovery, and quality issues; researches concerns, facilitates resolutions, and coordinates communication with leadership.
• Collaborates with internal teams to prepare for regulatory audits and external reviews; supports readiness, documentation preparation, corrective action plan monitoring, and cross-functional follow-through.
• Supports fraud, waste, and abuse prevention efforts through coordinated analytics, issue identification, and operational escalation processes.
• Supervises quantitative and qualitative analyses across QA, Recovery, and governance areas; interprets data, develops insights, and recommends process improvements.
• Partners with Training and other stakeholders to support readiness, operational training needs, and workflow enablement, maintaining dotted-line governance of the Training function.
• Maintains dotted-line governance of Provider Disputes (PDR) and Adjustments; ensures alignment, readiness, and cross-functional coordination, with the ability to assume full ownership of these operational areas as organizationally assigned.
• Promotes and maintains an environment that supports HPSJ’s strategy, vision, mission, and values.

Qualifications

• In-depth knowledge of Medi-Cal regulations and state-sponsored program requirements.
• Strong understanding of claims operations including processing, adjustments, PDR, recovery, QA, configuration, and their cross-functional interactions.
• Strong knowledge of audit processes, quality metrics, recovery methodologies, claims processing systems, and industry-standard payment practices.
• Strong analytical skills with ability to distill concepts, synthesize data, draw conclusions, and identify implications.
• In-depth knowledge of governance frameworks, operational readiness, project coordination, and execution management.
• Strategic mindset with ability to connect operational activities to enterprise priorities and future needs.
• Ability to influence and gain commitment across functional areas without direct authority.
• Strong communication skills, including written, verbal, presentation, and executive-level communication.
• Strong organizational savvy, complexity management, resourcefulness, decision quality, and ability to maneuver through cross-functional dynamics.
• Ability to plan, prioritize, align work, and ensure accountability across multiple teams and initiatives.
• Demonstrated ability to articulate and support HPSJ’s mission, vision, and values.
• Strong coaching, mentoring, and performance management skills.
• Intermediate proficiency in Word and Excel, including the ability to develop formulas and links.
• Ability to handle confidential information with appropriate discretion.

Requirements

• Bachelor’s Degree; and
• At least seven years progressively responsible healthcare claims experience, including claims administration, managed care operations, or cross-functional coordination; and
• At least four years Medi-Cal claims experience; and
• At least four years supervisory experience; or
• Equivalent combination of education and experience.

Preferred

• Experience in governance, recovery/payment integrity, workflow redesign, managed care, or operational analytics.
• Experience overseeing claims data analysis, QA functions, or complex transformation initiatives.

Benefits

• Robust and affordable medical coverage including HMO and PPO plan options.
• Employee Wellness Program promoting physical, mental, and financial well-being.
• Dental and vision plan with multiple provider choices.
• Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays, and 9 paid holidays).
• CalPERS retirement pension program, automatic employer-paid retirements contributions, plus a voluntary defined contribution plan.
• Two flexible spending accounts (FSAs) for healthcare and dependent care expenses.
• Employer-Paid Term Life and AD&D Insurance.
• Employer-Paid Disability Insurance.
• Employer-Paid Assistance Program (EAP).
• Health Advocacy to help you navigate medical care and benefits.
• Voluntary supplemental benefits including medical, legal, identity theft protection.
• Online discount mall.
• Tuition reimbursement.
• Remote work contingent on business needs and company guidelines.
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.

Physical Demands

Work may require frequent sitting, standing, and walking, constant repetitive motion, frequent talking and listening, closeup and distance vision requirements. Some work may require occasional travel based on the responsibilities of the position and business needs and occasional handling materials up to 50 pounds.

Emotional/Psychological Demands

Ability to cope with a fast-paced work environment, working under pressure, dynamic priorities and deadlines, constant decision making, working irregular hours, emotional and sensitive situations.

Work Environment

Work may be performed in a remote, hybrid, or onsite setting depending on the requirements of the position and business needs. For roles performed remotely, employees are expected to maintain a secure, distraction-free workspace, and reliable internet connectivity consistent with company standards.

Important Notice

The duties, qualifications, and physical and emotional requirements listed in this job description are not exhaustive. Health Plan of San Joaquin reserves the right to revise this job description at any time.