Institutional Claims Manager

We’re seeking an experienced Institutional Claims Manager to oversee all aspects of claims operations across professional, facility, and institutional lines of business under Knox-Keene full-risk arrangements. This role ensures compliance with regulatory and health plan requirements, including DMHC, CMS, and internal network policies for Choice Physicians Network (CPN), RINCON, and affiliated groups.

The Manager will lead and support the claims team in daily operations, performance monitoring, appeals and PDR oversight, and workflow optimization. This position requires strong leadership, analytical, and compliance skills, with the ability to collaborate across departments and drive operational excellence. Acting as a key departmental lead, the Claims Manager also provides oversight in the absence of senior leadership and plays a vital role in maintaining accuracy, efficiency, and regulatory integrity within all claims processes.