Director of Claims Quality and Excellence
4 days ago
Momentum Resource Solutions is seeking a highly skilled Director of Claims Quality to lead our Claims department in ensuring payment accuracy and promoting a continuous improvement culture.
The ideal candidate will have a strong background in claims operations, leadership experience, and a proven track record of driving organizational and operational changes using current and new technology.
This is a permanent role with a requirement for onsite work 2 days per week.
Key Responsibilities- Create, deliver, and facilitate a data and metrics-driven quality assurance and performance oversight program to ensure payment accuracy.
- Manage the benchmark process delivery from end to end, ensuring consistent benchmark reviews and quality and performance improvement plans.
- Develop deliberate, purposeful, and targeted quality reviews to identify payment inaccuracies and develop mitigation strategies.
- Track remediation plans through to completion.
- Manage and maintain a high-caliber provider reimbursement and analytics team.
- Develop and deliver clear and insightful stakeholder reports.
- Promote a continuous improvement culture.
- Build a high-performance environment and implement a people strategy that attracts, retains, develops, and motivates the team.
- Develop, update, and implement efficient and compliant workflows, policies, and procedures across the Claims department.
- Develop and enhance reporting capabilities.
- Develop a robust training curriculum.
- Keep abreast with regulatory requirements impacting claims processing.
- Responsible for internal and external audits for all lines of business.
- Coordinate with Compliance/Regulatory on DOH/DFS complaints, audit results, and ensure timely resolution.
- Act as Claims point of contact for the audit team.
- Establish, implement, and monitor audit corrective action plans.
- Responsible for UAT program for all lines of business.
- Liaison between claims and configuration to ensure claims rules are implemented and claims are processed accurately.
- Develop, provide, and support 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 ensuring integrity of claims payment.
- Collaborate with the Director of Claims Operations to improve end-to-end claims adjudication.
- Attend/assign staff to participate and represent claims in Joint Operation Committees with provider systems.
- Build strong/collaborative relationships with upstream and downstream departments.
- Participate in intradepartmental workgroups designed to improve claims performance and process.
- Provide support to the Claims Leadership team, senior leadership, and other MPH departments.
Minimum Qualifications
- 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.
- 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 the organizational and operational changes in the day-to-day business of a high-volume operation using current and new technology, achieving service excellence.
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