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Cedars-Sinai Director, Managed Care Operations (Claims) in Encino, California

Cedars-Sinai is known for its national leadership in transforming healthcare for the benefit of patients and the Medical Network is a critical component supporting the organization’s overall success. The Medical Network is seeking a Director, Managed Care Operations in the claims field to lead and manage the organizations portfolio.

We are recruiting an experienced Claims operator to enhance our Revenue Cycle buildout.

The Director will join the Medical Network during a time of significant transformation as the organization expands its Managed Care Operations. He/She will be responsible for full portfolio management, including optimizing and evolving the Managed Care Operations providing strategic leadership, ensuring that the Medical Network achieves its future business objectives.

The Director will be charged with evaluating the current business processes and determining the go-forward plan and appropriate staffing levels to deliver best in class service.

This role requires the Director to be business-focused and to maintain a balanced position between strategy and operational execution. The Director will be charged with partnering with business units to establish and prioritize demand as well as establish and communicate clear delivery metrics and implement an improved delivery process to ensure superior customer service. He/She will act as an agent of change to introduce new concepts of service and technology processes in a cost-effective manner and ensure continuous improvement while ensuring the appropriate services are delivered to the business. The Director should have comfort working initially with a significant amount of ambiguity as the organization continues through their business transformation.

He/She will be a self-motivated and visible leader who can develop trust and confidence with a variety of stakeholders. He/she will be expected to be the subject matter expert for all business applications and drive for results, positively impacting the overall strategic goals for Cedars-Sinai. The Director of Managed Care Operations develops, directs, implements, and oversees the management of the claims adjudication for all lines of Managed Care business at Cedars-Sinai. Responsible for managing the integrity of the claims payment and adjudication process to ensure all claims are processed accurately in accordance with contracted/non-contracted fee schedules, covered benefits, DOFR and Department of Managed Health Care (DMHC)/Health plan guidelines. Participates in the strategic planning process and works closely with the VP Revenue Cycle and Managed Care Operations.


The Director will have a broad set of responsibilities that will encompass the following:


▪ Maintain trusted business partnerships with VP Revenue Cycle and Managed Care, SVP of Operations, and senior leadership in finance, and information technology.

▪ Translate business needs to tactical Managed Care Operations project deliverables ensuring workflow integration, coordination, and optimization of best practices.

▪ Ability to manage complex projects and resources (people, costs, and time) across multiple sub-teams.

▪ Ability to communicate effectively at all levels of the organization including with executives, physicians, and nurses as well as communicate clearly and direct team to meet company, division, and team goals and objectives.

▪ Drive for high-quality results.

▪ Engage with key business partners in strategic discussions to further engagement.


▪ Maintain direct knowledge of current and future capabilities across the Managed Care Operational portfolio.

▪ Ability to establish the strategic direction and business plans for the business systems group.

▪ Work closely with other Medical Network leadership in developing short- and long-range plans and reviews these plans with senior Medical Network leadership as well as other organizational management.

▪ Monitor systems transactions and report on system disruptions.

Vendor Management

▪ Establish and direct strategic vendor partnerships that impact the effective delivery of application service to business functions.

▪ Hold application vendors accountable to negotiated SLAs, conduct monthly metrics reviews, and ensure committed levels of delivery of services.

Process and Methodology

▪ Bring a unique combination of operational expertise, change management and business process management principles, and strategic planning to drive operational effectiveness.

▪ Manage effective governance and portfolio management of business and financial applications to ensure stakeholder engagement, consensus on prioritization, effective resource management, and functional accountability through all phases of business and financial application and product lifecycle.

▪ Responsible for the delivery of systems on-time, on-budget, and in-scope.

▪ Establish remediation plans for work efforts that are not on target and risk mitigation strategies.


Direct the day-to-day operations of the Claims Department to ensure accurate and timely processing of members medical claims within established state and health plan compliance guidelines.

Identify and implement operational efficiencies and development of “best practice” policies and procedures that assure accurate, timely claim and encounter processing (written or verbal).

Identify business needs and drive change initiatives to address these issues.

Analyze customer impact and respond to complex escalated customer service and claims processing issues to ensure that customer expectations are consistently met.

Oversee all compliance standards for claims, ensuring operations are actively managing and reducing operational risk.

Oversee management of health plan audits/assessments, responses and CAP plans.

Responsible for implementation and achievement of budget goals and key performance indicators related to implementation of new business lines, recovery and revenue enhancement efforts for existing lines of business.

Understands, in detail, the daily, weekly, monthly and yearly metrics of the department and is able to make adjustments to hit predefined goals/objectives.

Ensures all EBA and DOFR rules are established correctly and audited periodically to ensure compliance with contracts through review of vendor contract configuration within Tapestry to assure accurate payments to our providers.

Maintain a full comprehensive understanding of the covered benefits, coding, reimbursement policies and contracts.

Ensure timely loading of encounter data, enrollment files and building of benefit plans.

Analyze, track and trend claim data; identify any potential service or systems issues; implement interventions, and determine success of intervention.

Recruit, hire, train staff, evaluate employee performance, and recommend or initiate promotions, transfers, and disciplinary action.

Partner with EIS on all Tapestry related build issues to mitigate compliance risk and ensure operational efficiency.

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Bachelor’s Degree in Business or Health Management required.

Experience required:

7 Years:

Direct experience in claims management and oversight, including overseeing benefit configuration, effective process flow implementation, and maintenance for commercial and government product lines.

Knowledge of Medicare, Medicare Advantage, Medi-cal, and commercial fee-for-service schedules, and industry regulations issued by the Center of Medicare and Medicaid Services ("CMS") and the Department of Managed Health Care ("DMHC") is required.

Demonstrated track record in creating workflows, policies and procedures to ensure effectiveness of the claims payment and adjudication process.

5 Years:

Demonstrated track record in creating workflows, policies and procedures to ensure effectiveness of the claims payment and adjudication process.

Direct supervisory experience with demonstrated success in managing and motivating staff.

Must possess solid communication skills.

Ability to build strong relationships with the health plans and DMHC.

Knowledge of all claims forms and coding types, including UB-04, CMS 1500, ICD-9 and ICD-10, HCPC, Revenue Codes and NDC coding, HIPPA, HEDIS, NCQA.

Knowledge of bundled payments, risk-sharing, and provider capitation is essential.

Proficient with Microsoft Word, Excel, Access, PowerPoint, and claims adjudication systems.

Well organized and able to multi-task.

Critical thinker who demonstrates problem solving skills for complex scenarios.

Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law.