MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
Position Overview:
The Director of Claims Quality has responsibility for the creation, delivery, and ongoing facilitation of a data and metrics-driven Claims Quality Assurance and Performance oversight program, which includes defining frameworks/benchmarks, calibration, and reporting of a program towards set benchmarks while promoting a continuous improvement culture.
Furthermore, the Director of Claims Quality is responsible for the management/oversight of claims quality, claims compliance, training and remediation, user acceptance testing (UAT), claims adjustments, and correspondence/inquiries/reconsiderations/appeals. This includes overseeing staffing, implementing, and maintaining policies, procedures, and workflows across the Claims department that is compliant with all applicable Local, State, and Federal Regulations. Also, this position is responsible for developing and enhancing reporting, monitoring performance, leveraging technology, tracking, and monitoring trends for multiple lines of business. The Director of Claims Quality is accountable for the coordination of all internal and external claims audit activities.
The incumbent will 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.