Director of Claims Quality - Tandym

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.

*This is a hybrid position with 3 days in the office and 3 days remote.

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.)