- Create, deliver, and facilitate a data and metrics-driven Claims Quality Assurance and Performance oversight program
- Manage claims quality, compliance, training, user acceptance testing, adjustments, and inquiries
- Develop and enhance reporting, monitor performance, and track trends
- Establish and monitor department objectives and productivity levels
- Implement efficient and compliant workflows
- Develop and implement provider appeal processes
- Stay updated on regulatory requirements impacting claims processing
- Conduct internal and external audits for all business lines
- Bachelor's Degree required, Master's Degree preferred
- 7-10 years of claims operations experience, with a minimum of 3 years in a leadership role
- Extensive knowledge of health plan claims industry regulations, policies, and processes
- Experience with claims testing, auditing, and quality assurance
- Integrity and Trust
- Customer Focus
- Functional/Technical Skills
- Written/Oral Communication
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Director of Claims Quality - Staten Island, United States - MetroPlusHealth
Description
MetroPlusHealth: Empowering New Yorkers Through Community Care
MetroPlusHealth is deeply committed to empowering New Yorkers by uniting communities through compassionate care. We firmly believe that healthcare is a fundamental right, not a privilege. If you possess a caring heart and a collaborative mindset, join us in making a difference. You'll find fulfillment in knowing that your work contributes to the well-being of others every day.
About MetroPlus Health:
MetroPlus Health offers top-tier healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens, and Staten Island. Our extensive range of products includes New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, and more. As a subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus Health boasts a network of over 27,000 primary care providers, specialists, and participating clinics. For over 30 years, we've been dedicated to fostering strong relationships with our members and providers to help New Yorkers lead their healthiest lives.
Position Overview:
The Director of Claims Quality plays a crucial role in overseeing and ensuring the quality and compliance of claims processes. This includes managing staff, establishing policies and procedures, enhancing reporting capabilities, and coordinating audit activities. Collaboration with other key team members is essential to maintain optimal performance within the Claims department.
Responsibilities:
The Director will also be involved in UAT programs, claims adjudication, staff training, and analyzing claims outcomes to drive improvement. Collaboration with various departments and participating in committees are key aspects of the role.
Minimum Qualifications:
If you have a passion for improving operational processes, a collaborative mindset, and the ability to drive organizational changes, we welcome your application. Join us in our mission to provide quality healthcare services to the diverse communities of New York City.
Professional Competencies:
The ideal candidate should possess strong interpersonal and communication skills, attention to detail, and a drive for continuous improvement. Proficiency in Microsoft Office tools and experience in health plan operational departments are desirable qualities for this role.
