Director, Claims

What you can expect! 

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

The Director, Claims is responsible for the direction and oversight of all medical claim processing, provider disputes & appeals, quality assurance, and training activities. Additional responsibilities include ensuring regulatory compliance, strategic planning, and staff development.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary.
• Hybrid schedule.
• State of the art fitness center on-site.
• Medical Insurance with Dental and Vision.
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development.
• Wellness programs that promote a healthy work-life balance.
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

1. Ensure all claims, appeals and disputes are accurately handled within Federal and State regulatory requirements.
2. Oversight of quality assurance audits and initiatives focused on payment accuracy and streamlined processes.
3. Oversight of all department training activities.
4. Primary department representation for internal/external claim audits and regulatory appeals and inquiries.
5. Responsible for ensuring regulatory reporting and fulfilling corrective action plans for identified deficiencies.
6. Coordinates department purchasing needs and originates RFP’s and RFQ’s for needed services.
7. Prepares department budget and staffing plan.
8. Ensure all department policies and provider manual claim policies are maintained.
9. Interacts with other IEHP departments to collaborate on key initiatives, issue resolution and Lean activities.

Education & Requirements 

• Five (5) years healthcare administration experience, four (4) or more years in a leadership capacity
• Two (2) years experience with an HMO or managed care experience
• Medi-Cal and/or Medicare claims experience preferred
• Bachelor’s degree in business administration, accounting or health care from an accredited institution is required
  • Master’s degree from an accredited institution preferred

Key Qualifications

• Solid understandings of rules and regulations governing Medi-Cal benefits and claims adjudication practices and procedures
• Principles and techniques of supervision and training
• Microcomputer literacy preferred

Start your journey towards a thriving future with IEHP and apply TODAY!

This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA.)