Director of Claims Excellence
4 weeks ago
Athari is seeking a highly skilled and experienced 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 Responsibilities- Create and implement a data-driven quality assurance and performance oversight program to ensure compliance with regulatory requirements and industry standards.
- Develop and maintain efficient and compliant workflows across the Claims department, ensuring accurate processing and timely resolution of claims.
- Manage the creation and delivery of clear and insightful stakeholder reports, providing transparency on overall quality and progress updates against key activities and outputs.
- 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, setting performance standards to meet service level agreements and contractual requirements.
- Develop and implement provider appeal workflows and processes, ensuring compliance with regulatory requirements.
- Develop and enhance reporting capabilities, leveraging technology to track and monitor trends for multiple 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, ensuring the claims universe, claim samples, audit responses, remediation, and resolution meet audit guidelines and timelines.
- 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, as well as adjudication strategies.
- Demonstrated experience with claims testing/auditing/QA, health care provider audit methods, and provider payment methods.
- Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes.
- Experience with multiple health plan operational departments, including configuration, medical management, provider operations, customer service, utilization management, regulatory, etc.
- Business process engineering experience preferred.
- Claims training experience or oversight preferred.
- A demonstrated track record of driving 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.
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