Job Description

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:

• Oversee and ensure accurate and timely claims payment processing, including managing vendor relationships to guarantee compliance with regulatory standards. Lead payment analysis to identify overpayments, underpayments, and discrepancies, and drive corrective action. Develop actionable insights to refine payment configurations and edits.
• Ensure compliance with federal, state, and provider contract requirements.

Claims Operations & Delegation Management:

• Supervise daily claims processing operations, ensuring the integrity of member benefits, fee schedules, and rule configurations. Collaborate with cross-functional teams to monitor and resolve issues related to claims, appeals, and recoupments. Ensure compliance with internal policies and regulatory requirements, including those set by external agencies.
• Support the external TPA in meeting agreed-upon service level agreements (SLAs).

Claims Appeals & Audits:

• Oversee the full lifecycle of claim appeals, working with internal teams to streamline processes and improve operational efficiency. Conduct audits to ensure claims payment and configuration integrity, and assist with the collection of data for regulatory inquiries and internal audits.

Management & Leadership:

• Provide leadership and direction for the team, including staff development, training, and performance management. Ensure staff are aligned with organizational objectives and regulatory requirements.
• Foster a collaborative environment and drive cross-departmental initiatives to improve processes and outcomes.

Strategic Oversight & Continuous Improvement:

• Identify opportunities to streamline workflows and enhance the claims processing system. Support the adaptation of automation tools and analytics technologies to improve reporting and data insights.

Qualifications:

Education:

• Bachelor’s degree in Business, Healthcare, Finance, or a related field.

Experience:

• A minimum of 5 years of experience in claims operations and medical economics within managed care or government programs (e.g., Medicaid, Medicare).
• At least 3 years of leadership experience managing staff and guiding cross-functional teams.
• In-depth knowledge of regulatory frameworks for Medicaid and Medicare programs.
• Strong analytical skills, with advanced proficiency in data analytics tools such as SAS, SQL, Tableau, and Microsoft Office Suite (Excel, Access, Visio, PowerPoint).

Other Skills:

• Exceptional communication and leadership skills.
• Ability to work independently, manage multiple projects, and solve complex problems.
• Strong attention to detail and organizational skills.

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