Remote Senior Manager of Claims Quality Assurance

XO Health believes healthcare is fixable. Become part of the community changing the face of the industry.

XO Health is the first health plan designed by and for self-insured employers that delivers a more unified health experience for everyone – from those who receive care, to those who deliver it, to those who pay for it.

We are growing a multi-disciplinary team of diverse and digitally empowered employees ready to rebuild trust in healthcare through comprehensive and unified transformation.

About the role:

The Sr. Manager of Claims Quality Assurance will implement, develop, and lead a successful Claims Quality Assurance and Compliance team for XO Health Claims Operations. The successful candidate will promote a continuous improvement culture, enhance the quality of claims handling, define the framework, benchmarking and identify areas for improvement across the portfolio of XO Health Claims. The successful candidate is a results-driven team player with a can-do mindset focused on continuous improvement and will support claims quality assurance and compliance objectives and strategies in partnership with XO Claims Operations Leadership and related internal stakeholders.

Responsibilities:

• Support development and execution of the XO Health Claims Quality Assurance & Compliance function within XO Claims with an immediate focus on continuously improving and enhancing this function in accordance with claims best practices and regulatory requirements.
• Collaborate with claims leadership and XO corporate compliance to develop and implement policies, standards, processes, controls, and related documentation of best practices, guidelines, and workflows to ensure a center of excellence within Claim Quality Assurance and Compliance.
• Support development and implementation of claims quality and audit processes for XO claims as well as Manager Quality File Reviews conducted by the claims managers to drive best in class claims handling.
• Support development and implementation of appropriate quality and compliance reviews of delegated/TPA claims service providers and vendors to ensure quality and appropriate claims service level results and compliance.
• Support development of meaningful, updated audits/questionnaires calibrated to claims best practices and current regulatory requirements, analyzing audit results, reporting on the results, and developing post-audit management action plans (MAPs) to drive continuous improvement.
• Monitor, coordinate, track, measure, and report internal audit findings to internal stakeholders to ensure claims have the necessary controls to assist, prioritize, manage, and mitigate risk.
• Develop and provide monthly, quarterly, and annual dashboard reporting for claims Quality Assurance and Compliance metrics to drive continuous improvement.
• Monitor updates of CMS, ERISA, Commercial guidelines, policies, and procedures.
• Collaborate with XO Claims Ops Leadership and related internal stakeholders on training initiatives, job aids, guidelines to continuously improve claims handling quality and execution in support of team and individual professional growth and development.
• Establish and maintain key relationships with internal (e.g., Peers, Payment Integrity/Actuarial, various executive management leaders) and external stakeholders (e.g., auditors, reinsurers, and vendors).
• Assist with other responsibilities or duties as needed.

Qualifications:

A qualified candidate will likely have:

• 7-10 years of experience with Quality Assurance and Compliance in CMS and commercial claims, reinsurance organizations with a complex operating environment. Experience working in the TPA (Third Party Administrator) organizations preferred.
• In-depth experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB04, Universal Claims, Stop Loss, Surgery, Anesthesia, DME, Behavioral Health, high dollar complicated claims, COB, Subrogation, and DRG pricing).
• In-depth knowledge of CMS, State, and ERISA laws and regulations related to healthcare claims processing.
• Ability to accomplish tasks in a dynamic environment with an aptitude for analyzing data and making practical and forward-looking decisions to drive success.
• Excellent communication skills and demonstrated ability and experience supporting strategic initiatives impacting key stakeholders and reporting to senior leadership.
• Experience working on cross functional teams, collaborating, actively participating, and delivering solutions.
• Strong organizational, critical thinking, problem solving, analytical, and quantitative skills including the ability to analyze and interpret financial and claims data.
• The ability to issue spot and escalate issues that could present challenges to a project or the organization.
• Strong conflict resolution skills to effectively deal with people with differing expectations and viewpoints.
• Strong knowledge of skills in use of various software and insurance platforms and systems, i.e. claims auditing platforms and claims systems.
• Excellent written and verbal communication skills.

Full compensation packages are based on candidate experience and relevant certifications.

$80,000—$90,000 USD

XO Health is an equal opportunity employer committed to diversity and inclusion in the workplace. All qualified applicants will receive consideration for employment without regard to sex (including pregnancy, childbirth or related medical conditions), race, color, age, national origin, religion, disability, genetic information, marital status, sexual orientation, gender identity, gender reassignment, citizenship, immigration status, protected veteran status, or any other basis prohibited under applicable federal, state or local law. XO Health promotes a drug-free workplace.