Director of Claims Quality and Analytics
2 days ago
We are seeking a highly skilled and experienced Director of Claims Quality and Analytics to join our team at RCM Health Care Services. As a key member of our leadership team, you will be responsible for driving the creation, delivery, and ongoing facilitation of a data-driven Claims Quality Assurance and Performance oversight program.
Key Responsibilities:- Develop and implement a data-driven Claims Quality Assurance and Performance oversight program to ensure payment accuracy and promote a continuous improvement culture.
- Manage and oversee provider reimbursement and analytics, claims quality analysts, claims compliance, training, and remediation, and user acceptance testing (UAT).
- Oversee staffing and implement and maintain policies, procedures, and workflows across the Claims department that are compliant with State and Federal Regulations.
- Develop and enhance reporting, monitoring performance, leveraging technology, tracking, and trending for multiple lines of business.
- Coordinate internal and external claims audit activities.
- Bachelor's Degree required; Master's Degree preferred.
- A minimum of 7-10 years claims operations experience in the managed care industry; a minimum of 3 years in a leadership role.
- 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 a plus.
- Business process engineering experience preferred.
- 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.
- 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.
We offer a competitive salary range of $160,000.00 to $170,000.00, excellent benefits, including a pension plan, and a dynamic work environment that fosters growth and development.
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