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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