Supervisor – Claims Delegation Oversight

Astrana Health

. Develop and implement operational strategies for external audit planning, readiness, execution, delivery, corrective action plan management, and audit-score improvement .

Posted 10/16/2026full-timeMonterey Park • California • United StatesMid-LevelSenior💰 $78,000 - $91,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in external audit management, including planning, execution, and compliance with DHCS and CMS regulations. Proven ability to lead teams, improve performance metrics, and implement strategic initiatives in a health plan environment.

Highest-signal resume keywords

External Audit ManagementClaims Administration ExperienceCMS Regulations KnowledgeLeadership SkillsProcess Improvement

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Claims Processing GuidelinesAudit Metrics ManagementRoot-Cause AnalysisData AnalyticsExcel ProficiencyHealth Plan AuditsStrategic PlanningPerformance Metrics ImprovementCorrective Action PlansMedi-Cal Guidelines

Soft Skills

Problem-SolvingMultitaskingCoachingInfluencingDecision-Making

Tools & Technologies

EzCapIDXCotivitiBurgessOffice Ally

Industry Keywords

Health PlanMedicareMedicaidClaims AdjudicationDMHC Regulations

About the role

Key responsibilities & impact

Develop and implement operational strategies for external audit planning, readiness, execution, delivery, corrective action plan management, and audit-score improvement
Lead, monitor, and oversee the end-to-end lifecycle of external audits, including health plan, DMHC, and CMS audits
Create, monitor, and manage audit metrics and goals
Track, trend, report, and communicate audit results
Collaborate with reporting teams to deliver accurate universe listings
Ensure supporting documents are timely and thoroughly reviewed before delivery
Conduct pre-audits to assess audit readiness and conformity with health plan and regulatory requirements
Lead root-cause analysis, remediation, prevention strategies, and process improvement for deficiencies
Manage corrective action plans for audit findings
Pull and approve scheduled and ad-hoc health plan reports
Review and approve audit documentation, workflows, policies, procedures, job aids, and standard operating procedures
Drive adherence to claims processes and legislative, regulatory, and contractual requirements
Oversee team training plans, training strategy, effectiveness measurement, and remediation
Build collaborative relationships across claims, utilization management, case management, pharmacy, eligibility, finance, compliance, configuration, network management, IT operations, and other departments
Collaborate with Claims Operations and Internal Audit on external audit strategy and prevention plans
Partner with IT and Data Analytics to maintain scorecards, dashboards, and reports
Collaborate with Configuration and IT teams to improve claims adjudication system configuration and rules
Recommend changes to claims-processing system design, rules, and workflows
Contribute to claims testing and audit strategy development
Conduct special projects, business analyses, strategic planning, and implementation efforts
Develop and execute strategic initiatives and programs
Set team goals and objectives, monitor performance metrics, and coach the team
Recruit, develop, motivate, and lead the team
Perform other duties as assigned

Requirements

What you’ll need

Solid understanding of DHCS and CMS rules and regulations governing claims adjudication practices and procedures
Detailed knowledge of Medi-Cal, Medicare, and Medicaid program guidelines
Advanced knowledge of CMS and DMHC regulations for analyzing and processing claims
Advanced reasoning, problem-solving, and planning skills
Ability to multitask, prioritize, and work in a fast-paced environment under minimal supervision
Proficiency in Excel, including creating and revising spreadsheets for accurate reports
Bachelor of Science, Bachelor of Arts, or equivalent education and experience required
3+ years of claims administration experience in a Health Plan/IPA/MSO setting
3+ years of experience with Health Plan Audits Delegation Audit functions and oversight
Proven success improving performance metrics, process improvement, cost reduction, and efficiency
Leadership skills, including coaching, mentoring, and fostering achievement
Strong independent decision-making, influencing, and analytical skills
Extensive knowledge of claims processing guidelines, prospective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelines
2+ years of people leadership experience
EzCap, IDX, Cotiviti, or Burgess experience
Experience with clearinghouses such as Office Ally
Experience managing offshore vendors
Core system implementation experience
Core system configuration experience

Benefits

Comp & perks

Hybrid work structure with work both in office and at home on a weekly basis
Equal Employment Opportunity and Affirmative Action employer
Reasonable accommodations available for applicants with disabilities