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Director of Claims Quality - Jersey City, United States - Tandym Group
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 Regulations
Developing and enhancing reporting, monitoring performance, leveraging technology, tracking, and trending for multiple lines of business
Coordination internal and external claims audit activities
Collaborating with and supporting the Director of Claims Operations and Director of Program Integrity as needed to ensure the Claims Department is running at optimal performance
Performing other duties, as needed
Qualifications:
7+ years of Claims Operations experience in the Managed Care industry
Bachelor's Degree
Previous experience in a Leadership role
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
Experience with Claims Testing / Auditing / QA
Solid problem solving and time management skills
Great interpersonal skills
Excellent communication skills (written and verbal)
Strong attention to detail
Highly organized
Desired Skills:
Master's Degree
Claims Training experience
Business Process Engineering experience
Experience with multiple Health Plan Operational departments (i.e., configuration, medical management, provider operations, customer service, utilization management, regulatory, etc.)
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