Director of Claims Quality

1 week ago

Williamsburg, Virginia, United States MetroPlusHealth Full time
Empower. Unite. Care.

MetroPlusHealth

is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.
About NYC Health + Hospitals

MetroPlus Health


provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc.

As a wholly owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus Health

network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus Health

has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life

Position Overview:


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, which includes defining frameworks/benchmarks, calibration, and reporting of a program towards set benchmarks while promoting a continuous improvement culture.

Furthermore, the Director of Claims Quality is responsible for the management/oversight of claims quality, claims compliance, training and remediation, user acceptance testing (UAT), claims adjustments, and correspondence/inquiries/reconsiderations/appeals.

This includes overseeing staffing, implementing, and maintaining policies, procedures, and workflows across the Claims department that is compliant with all applicable Local, State, and Federal Regulations.

Also, this position is responsible for developing and enhancing reporting, monitoring performance, leveraging technology, tracking, and monitoring trends for multiple lines of business.

The Director of Claims Quality is accountable for the coordination of all 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, which includes defining frameworks/benchmarks, calibration, and reporting of a program towards set benchmark.

Manage the benchmark delivery process 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 completionTrack remediation plans through to completion.

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.

Oversee and direct a team of managers, establishing and monitoring productivity goals, and monitoring inventory, cycle time, and work quality, ensuring accurate processing and timely resolution in accordance with regulatory and contractual guidelines.

Build a high-performance environment and implement a people strategy that attracts, retains, develops, and motivates their team by fostering an inclusive work environment, using a coaching mindset and behaviors, communicating vision/values/business strategy, and managing succession and development planning for the team.

Establish and routinely assess department objectives and productivity levels. Set performance standards to meet service level agreements as well as contractual, operational, and departmental standards and goals.
Develop, update, and implement efficient and compliant workflows across Claims department.
Develop and implement provider appeal workflows and processes.
Develop and enhance reporting capabilities.
Keep abreast with regulatory requirements as it impacts claims processing.
Responsible for internal and external audits for all lines of business.
Coordinate with Compliance/Regulatory on DOH/DFS complaints and audit results, ensuring timely resolution.
Act as Claims department 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.
Establish, implement, and monitor 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 the Claims and Configuration teams to ensure claims rules are implemented and claims are processed accurately, while driving auto-adjudication and quality improvement.

Develop, provide, and support the training of staff. Proactively identify strategies to strengthen training. Develop, enhance, and execute the 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.

Perform Root Cause Analysis of reasons for claim adjustments and inquiries/appeals to identify remediation strategies and opportunities to reduce rework.

Ensure solutions are compliant and implemented timely.

Collaborate with the Director of Payment Integrity to identify opportunities for financial recoveries and to ensure integrity of claims payments.

Collaborate with the Director of Claims Operations to improve end-to-end claims adjudication. Attend/delegate staff to participate and represent the Claims department in Joint Operation Committees with provider systems.

Build strong/collaborative relationships with upstream and downstream departments, including Provider Network Operations, to ensure timely resolution of provider inquiries and prevent escalation to DOH/DFS or other regulatory bodies.

Participate in intradepartmental workgroups designed to improve claims performance and process.
Provide support to the Claims leadership team, senior leadership, and other MPH departments.
Other duties as assignedMinimum Qualifications

Bachelor's Degree required.

Master's Degree preferred.7-10 years of claims operations experience in the managed care industry with a minimum of 3 years in a leadership roleKnowledge 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/QAExtensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentationProven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes.


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 preferredClaims training experience or oversight preferredA 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.

Proficiency in Microsoft Office – specifically Word, Excel, VISIO, and PowerPointProfessional CompetenciesIntegrity and TrustCustomer FocusFunctional/Technical skillsWritten/Oral CommunicationAbility to lead and work collaboratively, effectively, and efficiently with multidisciplinary teamsEffective written and verbal communication skills in a wide range of mediums.

Highly detail-oriented, resourceful, and self-motivated.
Polished interpersonal skills with emphasis on discretion and diplomacy.
Proven presentation and organizational skills

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