Director of Claims Quality Analytics Position
3 weeks ago
MetroPlus 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 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 over 30 years, MetroPlus Health has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest lives.
Position OverviewThe Director of Claims Quality Analytics is responsible for creating, delivering, and facilitating a data and metrics-driven Claims Quality Assurance and Performance Oversight program. This includes defining frameworks, benchmarks, calibration, and reporting of the program towards set benchmarks while promoting a continuous improvement culture. The Director of Claims Quality Analytics oversees claims quality, claims compliance, training, and remediation, user acceptance testing (UAT), claims adjustments, and correspondence, inquiries, reconsiderations, and appeals. This includes managing staffing, implementing, and maintaining policies, procedures, and workflows across the Claims department that is compliant with all applicable Local, State, and Federal Regulations.
Key Responsibilities- Create, deliver, and facilitate a data and metrics-driven quality assurance and performance oversight program.
- Manage the benchmark delivery process from end to end, ensuring consistent benchmark reviews and quality and performance improvement plans.
- Track remediation plans through to completion and manage the creation and delivery of clear and insightful stakeholder reports.
- 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.
- Build a high-performance environment and implement a people strategy that attracts, retains, develops, and motivates the team.
- Establish and routinely assess department objectives and productivity levels.
- Develop, update, and implement efficient and compliant workflows across the 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.
- Develop, provide, and support the training of staff.
- 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.
- 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.
- 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.
- 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 healthcare 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.
- 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.
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