Director Of Claims Quality

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The Director of Claims Quality has responsibility for the creation, delivery and ongoing facilitation of a data and metrics-driven Claims Quality Assurance and Performance oversight program to ensure payment accuracy, which includes defining frameworks/benchmarks, calibration and reporting of a program towards set benchmark while promoting a continuous improvement culture.

Furthermore, the Director of Claims Quality will be responsible for the management/oversight of provider reimbursement and analytics, Claims Quality analysts, claims compliance, training and remediation and user acceptance testing (UAT). This will include overseeing staffing and implementing and maintaining policies, procedures, and workflows across the Claims department that is compliant with State and Federal Regulations. Also responsible for developing and enhancing reporting, monitoring performance, leveraging technology, tracking, and trending for multiple lines of business.  The Director of Claims Quality is accountable for the coordination internal and external claims audit activities. 

The incumbent will foster a strong team environment, collaborating with and supporting the Director of Claims Operations and Director of Program Integrity as needed to ensure the Claims department is running at optimal performance.  

Job Description

• Create, deliver, and facilitate a data and metrics-driven quality assurance and performance oversight program to ensure payment accuracy, which includes defining frameworks/benchmarks, calibration and reporting of a program towards set benchmark.   
• Manage the benchmark process delivery from end to end, ensuring that benchmark reviews are conducted consistently, and that appropriate quality and performance improvement plans are created, facilitated and managed through to completion
• Develop deliberate, purposeful, and targeted quality reviews to identify payment inaccuracies and understanding/develop mitigation strategies to prevent future inaccuracies.
• Track remediation plans through to completion.
• Manage and maintain a high caliber provider reimbursement and analytics team, supporting provider contracting team.
• Manage the creation and delivery of clear and insightful stakeholder reports which are key to providing transparency on overall quality and progress updates against key activities and outputs.
• Promote a continuous improvement culture.
• Builds a high-performance environment and implements a people strategy that attracts, retains, develops, and motivates their team by fostering an inclusive work environment and using a coaching mindset and behaviors; communicating vision/values/business strategy; and managing succession and development planning for the team.
• Develops, updates, and implements efficient and compliant workflows, policies, and procedures across the Claims department
• Develops and enhances reporting capabilities.
• Develops a robust training curriculum
• Keep abreast with regulatory requirements as it impacts claims processing.
• Responsible for internal and external audits for all lines of business. Coordinates with Compliance/Regulatory on DOH/DFS complaints, audit results, ensures timely resolution. 
• Acts as Claims point of contact for the audit team. Responsible to ensure the claims universe, claim samples, audit responses, remediation and resolution meet audit guidelines and timelines. 
• Establishes, implements, and monitors audit corrective action plans.
• Responsible for UAT program for all lines of business, including creation of test scenarios, documentation of results and tracking the resolution of identified issues.
• Liaison between claims and configuration to ensure claims rules are implemented and claims are processed accurately, while driving auto-adjudication and quality improvement.
• Develops, provides, supports the training of staff. Proactively identifies strategies to strengthen training.
• Develop, enhances, executes quality assurance program to minimize inappropriate claims payment. Proactively identify strategies to strengthen the Claims Quality assurance program.
• Conduct ongoing analysis of Claims outcomes to identify trends, issues, and anomalies.
• Performs Root Cause Analysis of reasons for claim adjustments and inquiries/appeals to identify remediation strategies and opportunities to reduce rework. Ensures solutions are compliant and implemented timely.
• Collaborate with the Director of Payment Integrity, to identify opportunities for financial recoveries ensuring integrity of Claims payment.
• Collaborate with the Director of Claims Operations to improve end-to-end claims adjudication.
• Attends/assigns staff to participate and represent claims in Joint Operation Committees with provider systems.
• Builds strong/collaborative relationships with upstream and downstream departments
• Participates in intradepartmental workgroups designed to improve claims performance and process.
• Provide support to the Claims Leadership team, senior leadership, and other departments.
• Other duties as assigned

Minimum Qualifications

• Bachelor’s Degree required; Master’s Degree Preferred.
• A minimum of 7-10 years claims operations experience in the managed care industry; a minimum of 3 years in a leadership role
• Experience with multiple health plan operational departments (i.e., configuration, medical management, provider operations, customer service, utilization  management, regulatory, etc) a plus.
• Business process engineering experience preferred
• Knowledge of health plan claims industry regulations, guidelines, requirements, and policies including claims edit, coding and claims terminology.
• Working knowledge of Claims processing, correspondence and CRM platforms and adjudication strategies
• Demonstrated Experience with claims testing/auditing/QA
• Claims training experience or oversight preferred
• A demonstrated track record of driving the organizational and operational changes in the day-to-day business of a high-volume operation using current and new technology, achieving service excellence.