Claims Director

Join Us in Strengthening Care in Our Communities! Bring your vision and innovation to claims processing and help transform care for over 400,000 neighbors in five counties.

We welcome applicants from across California, with a strong preference for candidates based in our service areas (Santa Cruz, Monterey, Merced, Mariposa, and San Benito Counties). While this role may offer some remote flexibility, we value team members who are familiar with and connected to our local communities.

The Alliance is seeking a dynamic Claims Director to lead our claims operations and ensure timely, accurate service for members and providers across Santa Cruz, Monterey, Merced, Mariposa, and San Benito counties. This is a unique opportunity to make an impact locally, helping deliver quality, reliable care to more than 400,000 neighbors in our region. We're looking for a leader who brings both technical expertise and a passion for service, collaboration, and continuous improvement.

Be part of a mission-driven organization that values innovation, integrity, and community connection-while building your career in the heart of Central California.

THE IDEAL CANDIDATE

• A forward-thinking leader who is excited to bring innovative solutions to age-old challenges like inventory backlogs and lean staffing
• Proven ability to champion change initiatives by effectively communicating the vision, fostering buy-in, and motivating others to embrace new processes and ways of working
• Deep knowledge of claims regulations, policies, and systems, with the ability to translate complex requirements into efficient workflows
• Strategic thinker who can align claims management processes with organizational goals and regulatory requirements
• Experienced in building, coaching, and motivating high-performing teams while fostering accountability and collaboration
• Demonstrates high emotional intelligence, fostering positive relationships with team members, providers, and business partners
• Data-driven leader skilled in using metrics and analytics to monitor performance, identify trends, and implement improvements
• Proactive problem-solver who can navigate ambiguity, resolve escalated issues, and make sound decisions under pressure

Reporting to the Chief Operating Officer, this position:

• Provides strategic management oversight in implementing, directing, and monitoring the Alliance's Claims Department functions, including the development and implementation of new programs and services related to claims operations
• Directs and oversees the Claims Department, acts as a subject matter expert, and provides direction and advice related to Claims Department functions and overall business operations
• Directs, manages, and supervises Claims Department staff

WHAT YOU'LL NEED TO BE SUCCESSFUL

To read the full position description and list of requirements, click here.

• Knowledge of, and proficiency in:




• The principles and practices of claims operations and the claims function in a managed care environment
• Promoting and applying change management principles
• Research, analysis, and reporting methods
• California Medi-Cal program, Medicaid, Medicare, entitlement programs, and related regulations
• Healthcare regulatory processes and regulatory and contractual compliance activities




• Ability to:
  
  
  
  • Direct, manage, supervise, mentor, train, and evaluate the work of staff
  • Develop, plan, organize, and direct programs and activities that are complex in nature and regional in scope
  • Provide leadership, facilitate meetings, and partner with and guide managers and employees in the resolution of issues
  • Demonstrate strong analytical skills, accurately collect, manage, and analyze data, identify issues, offer recommendations and potential consequences, and mitigate risk
  • Assess departmental operations, identify opportunities for improvement, and advance operational effectiveness
  
  
  
  
• Education and Experience:
  
  
  
  • Bachelor's degree in Finance, Business Administration, or a related field
  • A minimum of ten years of claims operations experience in a managed care environment, which included some experience with financial management, a minimum of three years of experience working with Medicare and Medi-Cal Programs, and a minimum of five years of management-level experience (a Master's degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying
  
  
  
  

OTHER INFORMATION

• We are in a hybrid work environment, and we anticipate that the interview process will take place remotely via Microsoft Teams
• While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected
• In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process

The full compensation range for this position is listed by location below.

The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location).

Typical areas in Zone 1: Bay Area, Sacramento, Los Angeles area, San Diego area

Typical areas in Zone 2: Fresno area, Bakersfield, Central Valley (with the exception of Sacramento), Eastern California, Eureka area