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Head of Quality Assurance for Healthcare Claims
2 months ago
Position Overview:
The Director of Quality Assurance for Healthcare Claims is accountable for establishing, executing, and continuously improving a metrics-driven Claims Quality Assurance and Performance oversight initiative. This role involves defining benchmarks, calibrating processes, and generating reports to ensure adherence to established standards while fostering a culture of ongoing enhancement.
The Director will oversee claims quality management, compliance, training, and remediation efforts, as well as user acceptance testing (UAT), claims adjustments, and handling inquiries and appeals. This position is crucial in managing staffing, implementing policies, and ensuring workflows within the Claims department comply with all relevant regulations at local, state, and federal levels. Additionally, the Director will enhance reporting capabilities, monitor performance, leverage technology, and track trends across various business lines. Coordination of all internal and external claims audit activities falls under this role.
Key Responsibilities:
- Develop and implement a comprehensive quality assurance and performance oversight program, including defining benchmarks and reporting mechanisms.
- Manage the entire benchmark delivery process, ensuring consistent reviews and the creation of effective quality improvement plans.
- Oversee the completion of remediation plans and ensure timely delivery of insightful stakeholder reports that provide transparency on quality and progress.
- Encourage a culture of continuous improvement throughout the organization.
- Lead a team of managers, setting productivity goals and monitoring key performance indicators to ensure compliance with regulatory and contractual obligations.
- Foster a high-performance environment by implementing strategies that attract, retain, and develop talent while promoting an inclusive workplace.
- Regularly assess departmental objectives and productivity, establishing performance standards that align with service level agreements.
- Design and implement efficient workflows across the Claims department, including provider appeal processes.
- Stay updated on regulatory requirements impacting claims processing.
- Coordinate internal and external audits, ensuring compliance with audit guidelines and timelines.
- Act as the primary contact for audit teams, ensuring all audit-related activities are managed effectively.
- Develop and manage the UAT program, including the creation of test scenarios and documentation of results.
- Collaborate with the Claims and Configuration teams to ensure accurate claims processing and drive quality improvements.
- Provide training and support to staff, continuously enhancing the quality assurance program to minimize errors in claims payments.
- Conduct ongoing analysis of claims outcomes to identify trends and opportunities for operational improvements.
- Perform root cause analysis on claims adjustments and inquiries to identify strategies for reducing rework.
- Build collaborative relationships with various departments to ensure timely resolution of provider inquiries.
- Participate in workgroups aimed at enhancing claims performance and processes.
- Support the Claims leadership team and other departments as needed.
- Bachelor's Degree required; Master's Degree preferred.
- 7-10 years of experience in claims operations within the managed care sector, with at least 3 years in a leadership capacity.
- Thorough understanding of health plan claims regulations, guidelines, and policies.
- Experience with claims processing and quality assurance methodologies.
- Strong knowledge of healthcare provider audit methods and clinical aspects of patient care.
- Proven ability to apply data analysis techniques to enhance operational processes.
- Experience across multiple health plan operational departments is advantageous.
- Business process engineering experience is preferred.
- Demonstrated success in driving operational changes in high-volume environments.
- Proficiency in Microsoft Office applications, particularly Word, Excel, VISIO, and PowerPoint.
