Open Position: Claims Director

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. 

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

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

Open Position: Medicare Medical Director

The Alliance has an opportunity to join their team as the Medicare Medical Director.

Reporting to the Chief Medical Officer, this position:

• Acts as the Alliance’s Medicare Dual Eligible Special Needs Plan (D-SNP) clinical subject matter expert
• Provides specialized clinical D-SNP leadership within a variety of Health Services functional areas
• Develops and improves relationships with internal and external stakeholders, including the professional medical community, and maintains and enhances communications with similar Health Plan organizations
• Participates in all aspects of regulatory compliance related to D-SNP and Health Services functions

The Ideal Candidate

• Enjoys a fast-paced, demanding environment that requires critical thinking to develop and implement effective solutions in a timely manner 
• Is dedicated to caring for Medicare and/or Medicaid patients while addressing the social determinants of health
• Works with a broad and diverse group of stakeholders to problem solve and build cutting-edge programs
• Has the latitude to think broadly, make operational and strategic decisions, and oversee the implementation and continuous process improvement related to key internal and external priorities 

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

Open Position: Compliance Specialist II (Defined Term)

The Alliance has an opportunity to join their Compliance Department as a Compliance Specialist II.

This is a Defined Term position, which is designated by the Alliance and is a position of limited duration. Defined Term employees are usually hired to work in a specific department on specific long-term project work until the work is completed or to a specific end date not to exceed December 31, 2026. This is a Defined Term and fully benefited position.

Reporting to the Compliance Manager, this position: 

• Conducts regular on-going review and analysis of relevant contractual provisions and state and federal statutes and regulations
• Researches questions from staff regarding regulatory compliance and responds to external requests for information, including related to Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), and Centers for Medicare & Medicaid Services (CMS) requirements
• Assists with the implementation of internal and external audit processes to ensure compliance with federal and state statutes and regulations and provides related program guidance for all lines of business
• Coordinates Alliance delegate oversight activities to ensure subcontractors’ compliance with state, federal, and Alliance requirements
• Performs other duties as assigned

The Ideal Candidate

• Has experience working in a managed care or healthcare environment 
• Has knowledge of the Medi-Cal and Medicare Advantage programs and related regulations
• Is experienced in audits and monitoring, risk assessment, and/or delegate oversight
• Has an acute attention to detail and data accuracy 
• Has experience working remotely and knows how to self-motivate while staying closely connected to their team  
• Has excellent multitasking skills and thrives in a fast-paced environment 
• Is efficient with their time and can meet strict deadlines

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