Senior Manager, Claims Adjustments

Salary Range:  $117,509.00 (Min.) - $152,762.00 (Mid.) - $188,015.00 (Max.)

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
 

Job Summary

The Senior Manager, Claims Adjustments manages all adjustment-related operational workflows, including provider disputes, escalated claim reviews, complex adjustments, and litigation-related claim support. This position ensures that adjustment decisions are accurate, timely, consistent, and fully compliant with state, federal, and contractual requirements. The position functions as the operational leader for all claim adjustments that exceed routine examiner responsibilities and require higher-level investigation or coordination.

 

The Senior Manager leads a team of adjustment analysts and dispute specialists, building a culture of accuracy, documentation discipline, transparency, and initiative-taking issue identification.

 

The Senior Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.

Duties

Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities. Manages daily operations for all non-routine claim adjustments, including escalated cases, complex pricing reviews, and benefit or authorization-related adjustments. Ensures that adjustments are accurate, compliant, and completed within regulatory and contractual timeframes.

 

Oversees consistent application of payment rules, contract terms, and standardized work instructions. Builds and maintains clear adjustment pathways based on claim type, complexity, and regulatory requirements.

 

Oversees provider disputes requiring adjustment, including root-cause analysis and documentation of findings.

Ensures all provider adjustments meet Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), and contractual (TAT) requirements.

 

Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/ or executive management to define, prioritize, and develop projects and programs. Provides operational support for high-profile or complex provider inquiries involving reimbursement, coding, contract terms, or medical policy.

 

Manages communication with cross-functional departments and/or teams when needed. Ensures all adjustments are documented accurately and consistently, supporting audit readiness.

 

Partners with Compliance to validate adherence to regulatory standards and internal policies. Escalates potential compliance gaps or systemic issues that may require corrective action.

 

Partners with Legal to support claim-level discovery, case review, and preparation of adjustment packages.

Duties Continued

Provides operational insight on benefit application, contract interpretation, and pricing methodology relevant to legal inquiries. Ensures adjustments completed in relation to litigation or legal review are precise and audit ready.

 

Collaborates closely with cross-functional departments to resolve adjustment-related dependencies. Communicates root-cause drivers of adjustment volume and advocates for upstream corrections. Ensures adjustment processes are aligned with enterprise standards and system logic.

 

Develops reports and dashboards tracking adjustment volume, turnaround performance, accuracy trends, and systemic issues. Identifies trends in adjustment drivers and collaborates on upstream solutions that reduce rework.

 

Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures impl