Senior Claims Quality Director

4 weeks ago


New York, New York, United States Tandym Group Full time

A 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 payment accuracy.


Key Responsibilities:
  • Managing provider reimbursement and analytics, claims quality analysts, claims compliance, training and remediation, and user acceptance testing (UAT)
  • Overseeing staffing and implementing and maintaining policies, procedures, and workflows across the Claims Department that is compliant with State and Federal Regulations
  • Developing and enhancing reporting, monitoring performance, leveraging technology, tracking, and trending for multiple lines of business
  • Coordination internal and external claims audit activities
  • 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
  • Performing other duties as needed

Requirements:
  • 7+ years of Claims Operations experience in the Managed Care industry
  • Bachelor's Degree
  • Previous experience 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
  • Experience with Claims Testing / Auditing / QA
  • Solid problem-solving and time management skills
  • Great interpersonal skills
  • Excellent communication skills (written and verbal)
  • Strong attention to detail
  • Highly organized

Desired Skills:
  • Master's Degree
  • Claims Training experience
  • Business Process Engineering experience
  • Experience with multiple Health Plan Operational departments (i.e., configuration, medical management, provider operations, customer service, utilization management, regulatory, etc.)


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