Claims Quality Assurance Manager

At Collective Health, we’re transforming how employers and their people engage with their health benefits by seamlessly integrating cutting-edge technology, compassionate service, and world-class user experience design.

This role oversees the Customer Experience Quality Assurance Program, responsible for the day-to-day oversight of the Collective Health Quality Assurance Program (QAP).  This team plays a vital role in ensuring the accuracy, timeliness, and efficiency of claims processing for our employer-sponsored medical plans while addressing complex claims scenarios and maintaining compliance with regulatory and operational requirements.

• Key responsibilities of the QAP Manager include:
  
  
• Creating and implementing the Collective Health QA Program with the goals of safeguarding claims financial and procedural accuracy according to the health benefit plan’s intent.
• Developing, implementing and ensuring through reporting tools and resources  compliance with regulatory requirements, including monitoring for fraud, waste and abuse activities.
• Establishing and maintaining network and business partner relationships by collaborating and educating business associates on billing patterns that need improvement.
• Performing routine, moderate and complex audits on paper and electronic claims for payment integrity in alignment with appropriate health plan documents, internal policies, and according to generally accepted industry practices and standards. This includes scrutinizing and verifying the accuracy of medical claims for proper coding using ICD-10, CPT, and HCPCs codes, RBRVS, and DRG data.
• Collaborating with internal stakeholders and business partners to implement quality assurance strategies within the claims organization to allow for audit readiness with the goal to mitigate and/or avoid legal/ financial consequences due to non-compliance or inaccurate claims adjudication.
• Developing and implementing reporting needs in support of the QA program.
• Investigating and proactively detecting potential overpayments, underpayments, and coding errors on submitted claims utilizing a variety of manual and automated techniques to provide routine monitoring of claims processing financial and procedural accuracy.
• Ensuring appropriate coding and system configuration of claims and benefit plans with the ability to extract and audit exception reporting.
• Managing the intricate details of medical billing requirements, contract and  regulatory requirements, network partner relationships, and benefit application.
• Performing trend and root cause analysis and deriving from these reports  recommendations for claims accuracy improvement.
  
  
• Remediating identified issues to the root cause, including performing impact analyses and claim corrections to resolve any outstanding claims processing errors.  
• Provide technical support, training assistance and expertise to claims staff or other internal departments as determined by audit findings or as needed.
• Establishing,  preparing, and  presenting findings and corrective action steps  to Leadership, Compliance and other internal stakeholders.
• Developing and implementing documentation standards, policies and procedures for operational audits within the CX Claims Operations domain.
• Assessing medical records to confirm the medical necessity of billed services and adherence to clinical guidelines.
  
  
• As the Manager of the QAP,  you will lead these essential teams, driving their performance to achieve key metrics and ensuring operational excellence. Your role will include:
  
  
• Setting team goals and fostering a high-performing, collaborative culture.
• Provide direct managerial support, training and oversight of team members , and technical support staff within the unit.
• Coordinating work assignments within the department to achieve operational goals.
• Coaching and developing Team members to strengthen operational leadership across the organization.
• Streamlining and improving claims processing workflows to enhance efficiency and scalability.
• Staying current on coding updates and industry standards to maintain compliance.
• Partnering with other claims operations teams to optimize backend processes, systems, and policies. (Driving the operations side of engineering corrections, etc.)
  
  

In this role, you will play a critical part in ensuring the success and scalability of our claims operations, contributing directly to the efficiency and quality of our claims processes in a dynamic and fast-growing environment.

What you’ll do: 

• Lead and support the execution of day-to-day operations for our medical plan