Job Description:

A health services organization in New York City is currently seeking an experienced professional to join their staff as their new Director of Claims Quality. In this role, the Director of Claims Quality will be responsible for the creation, delivery and ongoing facilitation of a data and metrics-driven Claims Quality Assurance and Performance oversight program to ensure payment accuracy.Responsibilities:The Director of Claims Quality will be responsible for:Managing provider reimbursement and analytics, claims quality analysts, claims compliance, training and remediation and user acceptance testing (UAT)Overseeing staffing and implementing and maintaining policies, procedures, and workflows across the Claims Department that is compliant with State and Federal RegulationsDeveloping and enhancing reporting, monitoring performance, leveraging technology, tracking, and trending for multiple lines of businessCoordination internal and external claims audit activitiesCollaborating with and supporting the Director of Claims Operations and Director of Program Integrity as needed to ensure the Claims Department is running at optimal performancePerforming other duties, as neededQualifications:7+ years of Claims Operations experience in the Managed Care industryBachelor's DegreePrevious experience in a Leadership roleKnowledge 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 strategiesExperience with Claims Testing Auditing QASolid problem solving and time management skillsGreat interpersonal skillsExcellent communication skills (written and verbal)Strong attention to detailHighly organizedDesired Skills:Master's DegreeClaims Training experienceBusiness Process Engineering experienceExperience with multiple Health Plan Operational departments (i.e., configuration, medical management, provider operations, customer service, utilization management, regulatory, etc.)