The Director of Claims Integrity and Analytics is responsible for leading the comprehensive management of claims payment processes, ensuring the accurate and timely execution of claims. This includes overseeing third-party administrator (TPA) performance, maintaining the integrity of payment configurations, and managing claims appeals. The position requires collaboration with internal teams and external partners to ensure that claims payments are processed in accordance with contractual agreements and regulatory requirements. The role will also focus on optimizing the medical payment process to reduce costs and improve outcomes, while ensuring compliance with applicable regulations to prevent fraud, waste, and abuse (FWA). A strong understanding of healthcare policies, payment methodologies, and advanced analytical skills are essential.
Key Responsibilities:
Claims Payment Integrity:
Claims Operations & Delegation Management:
Claims Appeals & Audits:
Management & Leadership:
Strategic Oversight & Continuous Improvement:
Qualifications:
Education:
Experience:
Other Skills:
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