Current jobs related to Director of Claims Quality - New York - MetroPlus
-
Director of Claims Quality
1 month ago
New York, United States Tandym Group Full timeA health services organization in New York City is currently seeking an experienced professional to join their staff as their new Director of Claims Quality. In this role, the Director of Claims Quality will be responsible for the creation, delivery and ongoing facilitation of a data and metrics-driven Claims Quality Assurance and Performance oversight...
-
Director of Claims Quality
1 month ago
New York, United States MetroPlusHealth Full timeJob DescriptionJob DescriptionEmpower. 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 +...
-
Director of Claims Quality
5 months ago
New York, United States MetroPlusHealth Full timeEmpower. 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 + HospitalsMetroPlusHealth provides the highest...
-
Director of Claims Quality
3 months ago
New York, United States MetroPlusHealth Full timeEmpower. 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 + HospitalsMetroPlusHealth provides the highest...
-
Senior Claims Quality Director
6 days ago
New York, New York, United States Tandym Group Full timeA leading health services organization in New York City is seeking an experienced professional to fill the role of Senior Claims Quality Director at Tandym Group.In this position, the Senior Claims Quality Director will be responsible for the development and implementation of a data-driven Claims Quality Assurance and Performance oversight program to ensure...
-
Director of Claims Quality
1 month ago
New York City, United States MetroPlusHealth Full timeEmpower. 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 + HospitalsMetroPlusHealth provides the highest...
-
Director of Claims Quality Assurance
2 weeks ago
New York, New York, United States Tandym Group Full timeA leading health services organization in New York City is seeking an experienced professional to lead their Claims Quality Assurance and Performance oversight program. As the Director of Claims Quality, you will be responsible for creating, delivering, and facilitating a data-driven program to ensure payment accuracy.This is a hybrid position with 3 days in...
-
Director of Claim Quality Analytics
5 months ago
New York, United States MetroPlusHealth Full timeJob DescriptionJob DescriptionEmpower. 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 +...
-
Director of Claims Quality and Excellence
2 weeks ago
New York, New York, United States Momentum Resource Solutions Full timeJob SummaryMomentum Resource Solutions is seeking a highly skilled Director of Claims Quality to lead our Claims department in ensuring payment accuracy and promoting a continuous improvement culture.The ideal candidate will have a strong background in claims operations, leadership experience, and a proven track record of driving organizational and...
-
New York, New York, United States NYC Health Hospitals Full timeJob DescriptionMetroPlus Health provides high-quality healthcare services to residents of the Bronx, Brooklyn, Manhattan, Queens, and Staten Island through a comprehensive list of products, including New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, and more. As a wholly owned...
-
Director of Claims Quality Assurance
1 month ago
New York, New York, United States Athari Full timeJob DescriptionJob SummaryAthari is seeking a highly skilled Director of Claims Quality to lead our Claims department in delivering exceptional quality and performance. As a key member of our leadership team, you will be responsible for creating, delivering, and facilitating a data-driven quality assurance and performance oversight program.Key...
-
Director of Claims Excellence
3 weeks ago
New York, New York, United States Momentum Resource Solutions Full timeJob Title: Director of Claims QualityMomentum Resource Solutions is seeking a highly skilled Director of Claims Quality to join our team. As a key member of our Claims department, you will be responsible for ensuring the accuracy and efficiency of our claims processing operations.Key Responsibilities:Develop and implement a data-driven quality assurance...
-
Claims Director
2 days ago
New York, New York, United States Farmers Fire Insurance Full timeCompany OverviewFarmers Fire Insurance is a property and casualty insurance company that has been serving customers in our region since 1853. We work in partnership with a network of independent agents to meet the insurance needs of homeowners, renters, landlords, and small businesses. Our goal is to provide excellent service to our agents and customers...
-
Insurance Claims Director
2 days ago
New York, New York, United States Farmers Fire Insurance Full timeThe Farmers Fire Insurance Company is a property and casualty insurance provider located in Pennsylvania, serving customers since 1853.We work in partnership with a network of independent agents to meet the insurance needs of homeowners, renters, landlords, and small businesses.As a small insurance carrier, individuals have significant input into our...
-
Senior Claim Director
2 days ago
New York, New York, United States Axis Full timeSenior Claim Director - Specialty Complex ClaimsThis is a unique opportunity to lead a team of claims professionals in managing complex claims for AXIS Capital. As a Senior Claim Director, you will be responsible for overseeing the investigation, analysis, and evaluation of coverage, liability, and damages for claims involving significant potential severity...
-
Claims Quality Auditor
2 weeks ago
New York, New York, United States NYC Health Hospitals Full timeJob Title: Claims Quality AuditorAt NYC Health + Hospitals, we are committed to providing high-quality healthcare services to our community. As a Claims Quality Auditor, you will play a critical role in ensuring that our claims processing meets the highest standards of accuracy and compliance.Job SummaryThe Claims Quality Auditor is responsible for reviewing...
-
Claims Quality Auditor
4 weeks ago
New York, New York, United States MetroPlusHealth Full timeJob Title: Claims Quality AuditorMetroPlusHealth is seeking a highly skilled Claims Quality Auditor to join our team. As a Claims Quality Auditor, you will be responsible for reviewing claims to determine if payments have been made correctly. This position analyzes data used in settling claims to determine the validity of payment of claims and reports...
-
Claims Quality Auditor
4 days ago
New York, New York, United States MetroPlus Health Plan Full timeMetroPlus Health Plan is seeking a skilled Claims Quality Auditor to join our team. The ideal candidate will have a strong background in claims quality auditing and a keen eye for detail.**Job Summary:**As a Claims Quality Auditor, you will be responsible for reviewing claims to ensure accuracy and compliance with regulatory guidelines. You will analyze...
-
Claims Quality Auditor
1 month ago
New York, New York, United States MetroPlus Health Plan Full timeJob Title: Claims Quality AuditorAt MetroPlus Health Plan, we are committed to delivering high-quality healthcare services to our members. As a Claims Quality Auditor, you will play a critical role in ensuring that our claims processing systems are accurate and compliant with regulatory requirements.Job SummaryThe Claims Quality Auditor will be responsible...
-
National Director of Claims Leadership
3 days ago
New York, New York, United States Turner Construction Full timeJob SummaryTurner Construction is seeking a highly skilled National Director of Claims to lead our claims team nationwide. This is a remote role with the option of a hybrid working arrangement.About the RoleThe ideal candidate will have a strong general liability background with exposure to handling claims nationwide. They will be responsible for driving...
Director of Claims Quality
2 months ago
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
MetroPlusHealth 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, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth 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 completion
Track 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 assigned
Minimum 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 role
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
Extensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentation
Proven 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 preferred
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.
Proficiency in Microsoft Office – specifically Word, Excel, VISIO, and PowerPoint
Professional Competencies
Integrity and Trust
Customer Focus
Functional/Technical skills
Written/Oral Communication
Ability to lead and work collaboratively, effectively, and efficiently with multidisciplinary teams
Effective 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
