Director of Claims Quality and Analytics / Managed Care / Hybrid Role

Job ID: 241657    Posted 5/15/2024


Location: New York, New York


Job Type: Direct Hire


Category: HIM


Position: 241657




Salary Low: $160000 - Salary High: $170000


Duration: 2 Weeks



Job Description

For over three decades, this health plan has been dedicated to fostering strong connections with members and providers, empowering New Yorkers to lead their healthiest lives. They deliver top-notch healthcare services to residents across Bronx, Brooklyn, Manhattan, Queens, and Staten Island through a comprehensive range of products.

Director of Claims Quality – Hybrid Role (2 to 3 days in the Manhattan office and 2 to 3 days remote)

  • 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, which includes defining frameworks/benchmarks, calibration and reporting of a program towards set benchmark while promoting a continuous improvement culture.
  • Management/oversight of 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. 
  • Accountable for the coordination of internal and external claims audit activities.
  • Foster a strong team environment, 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. 

Minimum Qualifications

  • Bachelor’s Degree required; Master’s Degree Preferred.
  • A minimum of 7-10 years claims operations experience in the managed care industry; a minimum of 3 years in a leadership role
  • Extensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentation
  • Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes.
  • Experience with multiple health plan operational departments (i.e., configuration, medical management, provider operations, customer service, utilization  management, regulatory, etc) a plus.
  • Business process engineering experience preferred
  • 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
  • Demonstrated Experience with claims testing/auditing/QA
  • Claims training experience or oversight preferred
  • A demonstrated track record of driving the organizational and operational changes in the day-to-day business of a high-volume operation using current and new technology, achieving service excellence. 

Salary Range: $160,000.00 – $170,000.00 with excellent benefits (including a pension plan)

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At RCM Health Care Services, we redefine healthcare staffing, creating an environment where your career thrives and flourishes. Our commitment to your success is woven into the fabric of our culture, offering diverse opportunities for both seasoned professionals seeking challenges and newcomers ready to make their mark. As a part of the RCM family, you'll experience more than just a job – you'll find a platform for continuous growth and fulfillment.

We have cultivated an ecosystem where healthcare professionals not only find rewarding career opportunities but also a community that values their skills and dedication. Your success is our priority, and our collaborative environment ensures you're never alone on your professional journey. Competitive salaries and comprehensive benefits reflect our dedication to your well-being, allowing you to focus on what matters most – delivering exceptional care. Join RCM Health Care Services, a trusted partner with a proven track record since 1975 and embark on a journey where your path to a fulfilling healthcare career truly begins.

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With a legacy spanning over 45 years, RCM Health Care Services is a leader in connecting healthcare professionals with rewarding career opportunities. Our foundation is built on cultivating relationships with school districts, setting the stage for our expansion into placing providers across diverse facility types. As we evolved, our expertise diversified across various divisions including School Services, Behavioral Health/ABA, Travel, Nursing, Therapy, HIM, Permanent Placement, Foreign Recruitment, Locums Tenens, and much more.
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