Sr Director, Claim Quality Assurance and Process Improvement (Sr Dir Claims- QA & PI)
Sr Director, Claim Quality Assurance and Process Improvement (Sr Dir Claims- QA & PI)
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$ 150000 - 200000
1 Vacancy
Job Description
The Claims Quality and Process Optimization Leader will be responsible for developing and implementing quality assurance processes for Curatives Health Rules Payer (HRP) claims and configuration operations. They will oversee audits analyze trends and collaborate with teams to improve accuracy compliance and efficiency in claims processing. This role also supports improvements by: analyzing the current claims process identifying bottlenecks and areas for improvement and developing and implementing solutions to streamline operations reduce costs and enhance the overall claims experience
Responsibilities
Quality Assurance Oversight
- Develop and implement a quality assurance (QA) program with standards and best practices for claims handling alongside our claim leaders.
- Monitor and evaluate the accuracy of claims adjudication identifying discrepancies and leakage.
Auditing and Compliance
- Conduct routine and ad-hoc audits to ensure compliance with regulatory and organizational standards.
- Report audit findings and prepare actionable reports for leadership.
- Create calibration process to ensure standards are equally measured.
Training and Development
- Create training programs and materials to address performance opportunities identified through audit as well as training programs for staff on new processes and technologies to ensure proper implementation and adoption.
- Mentor and coach claims staff on quality assurance protocols and best practices.
- Develop training and controls to deliver first pass payment accuracy.
Performance Monitoring and Process Improvement
- Establish and track key performance indicators (KPIs) for claims quality.
- Collaborate with teams to set realistic goals and track progress over time.
- Analyze claims data to identify trends and areas for improvement.
- Work with cross-functional teams to recommend and implement process enhancements.
Stakeholder Communication
- Act as the primary liaison between QA and claims department teams to resolve issues.
- Present QA findings and improvement initiatives to leadership and stakeholders.
- Ability to drive best in class claims handling results through collaboration with department heads.
Measures of Success
- Develop and implement a quality operating model for claims payment accuracy that encompasses sampling as well as process-level quality performance.
- Achieve a sustained claims audit score of 98% or higher by year-end 2025
- Identify and address the recurring quality issues in claims handling.
- Reduce rework rate by at least 500 bps through targeted training and process
- Achieve a rework rate of less than 5%.
- Implement advanced analytics tools for QA monitoring.
Deliverables
- Quarterly QA performance reports including trends benchmarks and actionable recommendations.
- Comprehensive training materials for claims teams.
- Updated QA protocols and workflows.
- Action plans to address recurring claims processing errors.
Qualifications
- Proven experience developing and leading a quality assurance program within an operational area
- Preferred: Strong working knowledge of HealthEdge HRP Claim Processing system
- Preferred: Formal experience with process improvement disciplines (Lean Six Sigma) and demonstrated implementation projects
- Thorough understanding of regulatory and client performance guarantee principles as well as the end-to-end processes of health insurance operations.
- Critical thinking analytical skills and talent development skills are critical.
- Leadership skills; ability to plan organize delegate and empower staff.
- Effective communication skills; ability to obtain and deliver information to others orally and in written form.
- Ability to work with little supervision and direction.
- Ability to operate business technology.
- Bachelors degree or 10 years equivalent experience and skills required.
- Working expertise with Google Workspace software (Google Docs Sheets Gmail Sides Forms)
Required Experience:
Director
Employment Type
Full-Time
