Director Claims Quality Audit

Profile

Description

Humana Military is the Managed Care Support Contractor (MCSC) for the Department of Defense (DoD) charged with administering the TRICARE health plan in the East Region. While the contract is responsible for processing claims for more than 6 million members, the claims processing and financial management functions are outsourced to an external vendor. The Claims Oversight department has responsibility overseeing the vendor's claims processing operations and systems. The Director, Claims Oversight plays a vital role in ensuring claims performance meets and exceeds the contract requirements. The department is comprised of four units: claims operations, claims systems change management, claims research and response (internal and external customers), and claims data and reporting. The individual in this role will care for key relationships with leaders across the organization whose functions are impacted by claims processing to include but not limited to, Medical Management, Customer Service, Network Operations, and Consumer Experience. They will also serve as the primary point of contact for inquiries and requests received from the Government as they relate to claims.

Responsibilities

The Director, Claims Quality Audit will oversee and collaborate with the vendor's claims and IT leaders to ensure all accuracy and timeliness metrics are met and exceeded. This role will also ensure complete and accurate information is reported to the Government through routine reporting or ad hoc requests. Finally, the individual in this role will bring technical expertise and monitor industry to bring forward strategic opportunities for Humana Military to advance technologies and processes to improve claims processing and the resulting consumer experience.

The individual in this role needs to thrive in a complex, high-pressure environment, while maximizing resources and producing exceptional results to the TRICARE Program.

In this role you will:


Develop and execute strategies to meet and exceed contractual requirements related to the TRICARE Program related to claims processing.
Ensure claims processes and policies support compliance with the TRICARE Program rules and regulations
Establish and manage goals, priorities, staffing and budgets for the Claims Oversight and Claims Operations departments
Develop and maintain strong collaborative business relationships with leaders across the Humana Military organization and Defense Health Agency
Monitor industry trends to advance strategies to improve claims processing proficiencies


Our Department of Defense Contract requires U.S. citizenship for this position.

Required Qualifications


10 years leadership experience in healthcare insurance industry over a claims related area
Bachelor's Degree
5 years claims processing operations experience
Extensive experience with process improvement
5-10 years of health care industry knowledge in Medicare OR TRICARE
5 Years of Claims Operations knowledge
Strong communication, organizational, and decision making skills
Track record of building strong relationships
Must be passionate about contributing to an organization focused on continuously improving consumer experiences


Preferred Qualifications


Master's degree or MBA
Experience with Medicare, Medicaid and/or Tricare


Scheduled Weekly Hours

40

Company info

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