Current jobs related to Director of Claims Quality - Albany - MetroPlusHealth

  • Property Claims Adjuster

    4 weeks ago

    Albany, New York, United States CCMS & Associates Full time

    Job OverviewCCMS & Associates is in search of a 1099 Field Adjuster. We are expanding our team and looking for qualified candidates to join our innovative workforce.Position SummaryWe are interested in hiring a field adjuster with a background in either residential or commercial claims, possessing a minimum of 1 year of field experience.Qualifications:At...

  • Claims Examiner

    1 month ago

    Albany, United States Mindlance Full time

    Description: Manager's Note: Work location: Telecommuter NY Job location: Hybrid Years of experience: At least 2-3 years Any specific skill/ certification/ license/ experience: NY License. Job Description: PRIMARY PURPOSE: To analyze complex or technically difficult workers' compensation claims to determine benefits due; to work with high exposure claims...

  • Field Roof Technician

    1 month ago

    Albany, United States Hancock Claims Consultants Technicians Full time

    Job DescriptionJob DescriptionCLIMB to New Heights…And live the American Dream. Become part of something bigger by contracting with the nation’s top provider of roof and property inspection services working with insurance carriers and adjusters in your area. This is an independent contractor position.We are seeking professional inspectors to join our...

  • Field Roof Technician

    2 weeks ago

    Albany, United States Hancock Claims Consultants Technicians Full time

    Job DescriptionJob DescriptionCLIMB to New Heights…And live the American Dream. Become part of something bigger by contracting with the nation’s top provider of roof and property inspection services working with insurance carriers and adjusters in your area. This is an independent contractor position.We are seeking professional inspectors to join our...

  • Project Manager

    2 weeks ago

    Albany, New York, United States The LiRo Group Full time

    About the RoleWe are seeking a highly skilled Project Manager / Claims Analyst to join our team at The LiRo Group. As a key member of our construction management team, you will be responsible for analyzing delay claims brought against the State within a geographic region.Key ResponsibilitiesPerform review, interpret, and perform complex schedule analysis...

  • Claims Examiner

    5 days ago

    Albany, United States BCForward Full time

    Job DescriptionJob DescriptionBCforward is currently seeking a highly motivated Claims Examiner - Workers Compensation in Melville, NY. Position Title: Claims Examiner - Workers Compensation Location: Melville, NY (Hybrid)Anticipated Start Date: ASAPPlease note this is the target date and is subject to change. BCforward will send official notice ahead of a...

  • Claims Risk Management Specialist

    4 weeks ago

    Albany, New York, United States Albany Medical Center Full time

    Department/Unit:Risk ManagementWork Shift:Day (United States of America)Position Summary:Salary: $80,132,249.00 USD AnnualThe Risk Manager will be responsible for developing comprehensive litigation strategies aimed at effectively managing claims. This role involves collaboration with external legal counsel, engaging experts, life care planners, structure...

  • Regional Therapy Director

    4 weeks ago

    Albany, United States QRM (Quality Rehab Management) Full time

    QRM is seeking an experienced Therapy/Rehab Program Manager well versed in Clinical Reimbursement and Patient Driven Payment Model (PDPM) in the arena of rehab relating to Physical, Occupational, and Speech Therapy. Must be a NJ or NY licensed PT/OT/SLP with multi-site SNF management experience, background in operations and with clinical expertise, and...

  • Regional Therapy Director

    1 week ago

    Albany, United States QRM (Quality Rehab Management) Full time

    QRM is seeking an experienced Therapy/Rehab Program Manager well versed in Clinical Reimbursement and Patient Driven Payment Model (PDPM) in the arena of rehab relating to Physical, Occupational, and Speech Therapy. Must be a NJ or NY licensed PT/OT/SLP with multi-site SNF management experience, background in operations and with clinical expertise, and...

  • Podiatrist Opportunity in Skilled Nursing Facilities

    7 days ago

    Albany, Georgia, United States Medical Director Services PC Full time

    Podiatrist Job DescriptionMedical Director Services PC is seeking experienced Podiatrists to provide medical services to patients in skilled nursing facilities throughout Georgia. Inquire about availability in other states as well.Job Summary:Provide professional and medical podiatric services to patients with conditions affecting the foot, ankle, and...

  • Podiatric Care Specialist

    1 week ago

    Albany, New York, United States Medical Director Services PC Full time

    Podiatrist Job OpportunityWe are seeking an experienced Podiatrist to provide medical services to our skilled nursing facilities in Georgia. If you are interested in expanding your practice to other states, please inquire about availability.Job SummaryAs a Podiatrist with Medical Director Services PC, you will provide professional and medical podiatric...

  • Podiatric Care Specialist

    4 days ago

    Albany, New York, United States Medical Director Services PC Full time

    Podiatrist OpportunityMedical Director Services PC is seeking an experienced Podiatrist to provide medical services to our skilled nursing facilities throughout Georgia. Inquire about availability in other states as well. Now Offering a Sign-On Bonus.Job SummaryProvide professional and medical podiatric services to patients with conditions affecting the...

  • Podiatric Care Specialist

    4 days ago

    Albany, New York, United States Medical Director Services PC Full time

    Podiatrist OpportunityWe are seeking an experienced Podiatrist to provide medical services to our skilled nursing facilities in Georgia. In addition to Georgia, we also have opportunities in other states. A sign-on bonus is now available.Job SummaryAs a Podiatrist with Medical Director Services PC, you will provide professional and medical podiatric services...

  • Podiatrist Opportunity in Skilled Nursing Facilities

    7 days ago

    Albany, Georgia, United States Medical Director Services PC Full time

    Podiatrist Job DescriptionMedical Director Services PC is seeking experienced Podiatrists to provide medical services to patients in skilled nursing facilities throughout Georgia. Inquire about availability in other states as well.Job Summary:Provide professional and medical podiatric services to patients with conditions affecting the foot, ankle, and...

  • Podiatric Physician

    52 minutes ago

    Albany, New York, United States Medical Director Services PC Full time

    Podiatrist Job OpportunityMedical Director Services PC is seeking an experienced Podiatrist to provide medical services to patients with conditions affecting the foot, ankle, and related structures in skilled nursing facilities throughout Georgia. Inquire about availability in other states as well.Job Summary:Provide professional and medical podiatric...

  • Podiatric Specialist

    2 weeks ago

    Albany, New York, United States Medical Director Services PC Full time

    Job Summary:Medical Director Services PC is seeking an experienced Podiatric Specialist to provide medical podiatric services to patients with conditions affecting the foot, ankle, and related structures in skilled nursing facilities throughout Georgia. The ideal candidate will have a strong background in providing essential at-risk foot care to the...

  • Podiatrist

    3 days ago

    Albany, United States Medical Director Services PC Full time

    Medical Director Services PC is looking to hire experienced Podiatrist s to service our skilled nursing facilities throughout Georgia . Inquire about availability in other states as well! Now Offering a Sign-On Bonus! Summary: Provide professional and medical podiatric services to patients with conditions affecting the foot, ankle, and related...

  • Software Quality Assurance Lead

    2 weeks ago

    Albany, New York, United States Versant Health Full time

    Job SummaryVersant Health is seeking a highly skilled Software Quality Assurance Lead to join our team. As a key member of our quality assurance team, you will be responsible for ensuring the quality of our software products and services.Key ResponsibilitiesDevelop and implement effective quality assurance processes and procedures to ensure high-quality...

  • Podiatrist - Skilled Nursing Facilities

    1 week ago

    Albany, New York, United States Medical Director Services PC Full time

    Job SummaryWe are seeking experienced Podiatrists to provide medical services to our skilled nursing facilities throughout Georgia. Inquire about availability in other states as well.ResponsibilitiesProvide essential at-risk foot care to the Geriatric populationDiagnose, treat, or prescribe treatment of the foot, ankle, and other related structures using...

  • Executive Director

    1 month ago

    Albany, United States Catholic Charities of the Diocese of Albany Full time $75,000 - $90,000

    Job DescriptionJob DescriptionExecutive DirectorCatholic Charities Housing OfficeImagine working in a place where you have the ability to partner with a diverse network of Community Partners to spearhead programs to prevent homelessness by enhancing the availability of secure, affordable housing options. As the Executive Director (ED) of the Catholic...

Director of Claims Quality

3 months ago

Albany, 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 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

#J-18808-Ljbffr