Head of Quality Assurance for Healthcare Claims

1 week ago

New York, New York, United States Innova Solutions Full time

Position Overview:
The Director of Claims Quality is tasked with establishing, executing, and continuously enhancing a metrics-driven Claims Quality Assurance and Performance oversight initiative. This role encompasses the development of frameworks and benchmarks, calibration, and reporting aligned with predetermined standards while fostering a culture of continuous improvement.

The Director will oversee claims quality management, compliance, training, user acceptance testing (UAT), claims adjustments, and inquiries including appeals. Responsibilities include managing staffing, implementing policies, and ensuring adherence to all relevant regulations at local, state, and federal levels. Additionally, this position will enhance reporting capabilities, monitor performance, leverage technology, and track trends across various lines of business. The Director will coordinate all internal and external claims audit activities.

Key Responsibilities:

  • Design and implement a data-driven quality assurance and performance oversight program, defining benchmarks and ensuring consistent review processes.
  • Oversee the end-to-end management of benchmark delivery, ensuring quality improvement plans are developed and executed effectively.
  • Track and manage remediation plans to ensure completion.
  • Produce comprehensive stakeholder reports that provide transparency on quality metrics and progress updates.
  • Encourage a culture of continuous improvement within the team.
  • Lead a team of managers, setting productivity goals and monitoring performance metrics to ensure compliance with regulatory standards.
  • Foster a high-performance environment, implementing strategies to attract, retain, and develop talent within the team.
  • Establish and evaluate departmental objectives and productivity metrics, ensuring alignment with service level agreements.
  • Develop and maintain efficient workflows across the Claims department.
  • Enhance reporting capabilities to support decision-making.
  • Stay informed on regulatory changes impacting claims processing.
  • Coordinate internal and external audits across all business lines.
  • Act as the primary contact for audit teams, ensuring compliance with audit guidelines.
  • Manage the UAT program, including the creation of test scenarios and documentation of results.
  • Collaborate with Claims and Configuration teams to ensure accurate claims processing.
  • Provide training and support to staff, continuously identifying opportunities to strengthen training programs.
  • Conduct ongoing analysis of claims outcomes to identify trends and areas for improvement.
  • Perform root cause analysis on claims adjustments and appeals to develop effective remediation strategies.
  • Collaborate with other departments to enhance claims adjudication processes.
  • Participate in workgroups aimed at improving claims performance.
  • Support the leadership team and other departments as needed.
  • Other responsibilities as assigned.

Minimum Qualifications:

  • Bachelor's Degree required; Master's Degree preferred.
  • 7-10 years of experience in claims operations within the managed care sector, including at least 3 years in a leadership capacity.
  • In-depth knowledge of health plan claims regulations and policies.
  • Experience with claims processing and quality assurance methodologies.
  • Strong understanding of healthcare provider audit methods and clinical aspects of patient care.
  • Ability to apply data analysis techniques to enhance operational processes.
  • Familiarity with various health plan operational departments is advantageous.
  • Experience in business process engineering is preferred.
  • Proficiency in Microsoft Office applications.

About Innova Solutions:
Innova Solutions is a leading provider of strategic technology and business transformation solutions, dedicated to enabling clients to excel in their respective fields.

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