Claims Manager - Hybrid - 138610

The Managed Care Claims Manager is responsible for the overall leadership, strategic oversight, and operational performance of the claims adjudication process within the managed care division. This position ensures that claims and encounters are processed accurately, efficiently, and in full compliance with regulatory, contractual, and industry standards. The Manager oversees claim adjudication workflows, monitors operational trends, and implements process improvements to optimize quality, timeliness, and regulatory adherence. This position is also responsible for maintaining readiness for health plan audits, overseeing the team that responds to data requests and implementing audit-driven improvements as well as overseeing encounter submission and rejection resubmission of encounters to health plans.

• Nine (9) years of related experience in medical claims processing, claim adjudication, encounter reporting, claims operations management, OR a Bachelor's degree in a related field plus five (5) years of related experience. Related experience includes supervisory or leadership experience in a healthcare claims environment (health plan, provider group, IPA, MSO, TPA, or managed care organization).

• Solid knowledge of the principles, concepts, systems, processes, quality improvement plans, and best practices needed for effective and successful operations in managed care contacting.

• Ability train and guide employees on techniques.

• Knowledge of medical center, HR and UC policies and processes. Solid knowledge of applicable federal, state and local laws and regulations.

• Demonstrated skills in employee supervision and HR administration. Leadership skills to motivate and inspire staff to improve Managed Care services.

• Demonstrated ability to prioritize effectively to meet deadlines in a complex, challenging environment.

• Solid organizational and customer service skills to structure unit operations and lead assigned staff in an efficient and effective manner.

• Interpersonal skills to work collaboratively, coordinate and integrate with others throughout the organization. Maintains cooperative working relationships with professional and administrative staff, peers, multidisciplinary team members, management, and external managed care representatives. Ability to positively influence subordinates in conflict resolution, and knowledge of when to escalate conflict intervention.

• Strong critical thinking skills, with the ability to quickly analyze and evaluate complex and difficult problems, and sensitive situations, determine appropriate level of intervention, and develop and apply effective solutions.

• Solid verbal and written communication skills to explain technical Managed Care concepts, actively listen, persuade, advise, and counsel.

• Strong computer proficiency in all relevant hardware, software, and specialty contract databases and applications used in the department. Ability to synthesize data and utilize computerized systems to produce meaningful reports on department operations, results, and performance.

• Experience working in a delegated claim processing environment.

• Experience processing claims in Epic Tapestry.

• Extensive knowledge of medical claims processing across all claim types, including professional, facility/institutional, ancillary, and specialty claims.

• In depth understanding of claim adjudication methodologies, including coding principles (ICD 10, CPT, HCPCS), billing guidelines, benefit structures, coordination of benefits (COB), and Explanation of Benefits (EOB) logic.

• Strong working knowledge of state and federal claims regulations, including but not limited to: CMS Medicare Advantage guidelines, Commercial plan claims requirements, Timely filing laws,Interest/penalty rules, Clean claim standards, HIPAA transaction standards (837/835).

• Experience overseeing claims appeals, disputes, adjustments, and reprocessing workflows.

• Knowledge of encounter submissions, encounter error/rejection management, and compliance with health plan encounter reporting requirements.

• Demonstrated ability to lead claims teams, including training, performance management, quality monitoring, and workflow oversight.

• Strong competency in evaluating operational trends, identifying root causes, and implementing process improvements based on quality, timeliness, accuracy, and audit findings.

• Experience ensuring audit readiness and responding to data requests from health plans, regulatory agencies, or internal compliance departments.

• Strong analytical and critical thinking abilities to interpret complex claim rules, resolve escalated claim issues, and make operational decisions.

• Ability to synthesize data, run claim related reports, and use claims processing systems and analytics tools to monitor team performance and operational results.

• Excellent written and verbal communication skills to explain claims logic, regulatory requirements, and process guidance to staff and stakeholders.

• Ability to work collaboratively with internal departments (billing/rev cycle, provider relations, UM, IS) and external partners such as health plans and providers.

• Skilled in conflict management and knowing when to escalate complex personnel or operational issues.

• Must be able to work various hours and locations based on business needs.

• Employment is subject to a criminal background check and pre-employment physical.

If employed by the University of California, you will be required to comply with our Policy on Vaccination Programs, which may be amended or revised from time to time. Federal, state, or local public health directives may impose additional requirements.

If applicable, life-support certifications (BLS, NRP, ACLS, etc.) must include hands-on practice and in-person skills assessment; online-only certification is not acceptable.

UC San Diego Health is the only academic health system in the San Diego region, providing leading-edge care in patient care, biomedical research, education, and community service. Our facilities include two university hospitals, a National Cancer Institute-designated Comprehensive Cancer Center, Shiley Eye Institute, Sulpizio Cardiovascular Center, the only Burn Center in the county, and and dozens of outpatient clinics. We invite you to join our team!

Applications/Resumes are accepted for current job openings only. For full consideration on any job, applications must be received prior to the initial closing date. If a job has an extended deadline, applications/resumes will be considered during the extension period; however, a job may be filled before the extended date is reached.

To foster the best possible working and learning environment, UC San Diego strives to cultivate a rich and diverse environment, inclusive and supportive of all students, faculty, staff and visitors. For more information, please visit UC San Diego Principles of Community.

The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law.

For the University of California's Anti-Discrimination Policy, please visit: https://policy.ucop.edu/doc/1001004/Anti-Discrimination

UC San Diego is a smoke and tobacco free environment. Please visit smokefree.ucsd.edu for more information.

UC San Diego Health maintains a marijuana and drug free environment. Employees may be subject to drug screening.

Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts an offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; or have filed an appeal of a finding of substantiated misconduct with a previous employer.

a. "Misconduct" means any violation of the policies governing employee conduct at the applicant's previous place of employment, including, but not limited to, violations of policies prohibiting sexual harassment, sexual assault, or other forms of harassment, or discrimination, as defined by the employer. For reference, below are UC's policies addressing some forms of misconduct:

• UC Sexual Violence and Sexual Harassment Policy
• UC Anti-Discrimination Policy
• Abusive Conduct in the Workplace