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.
  
  

• 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 plans, ensuring operational rigor, performance management, and team development. Key responsibilities include:
• Team Leadership & Performance Management: Manage a team of Quality Auditors (Specialist?) providing coaching, feedback, and professional development to ensure high performance and effective team management. Implement performance management processes to track and improve individual and team outcomes.
• Identify and Mitigate Risks: Proactively identify risks in existing processes and develop strategies to mitigate those risks, ensuring continuous improvement in operations.
• Enhance Reporting & Operational Rigor: Develop and refine reporting capabilities to provide actionable insights, maintain operational rigor, and develop and track key performance indicators (KPIs) across teams. Ensure adherence to operational standards and drive consistency across all processes.
• Subject Matter Expertise in Claims Operations: Serve as a health plan policy operations expert with a deep understanding of claims processing, including medical claims adjudication, coding procedures, regulatory requirements, and compliance standards. Utilize this expertise to guide the team in resolving complex claims issues, optimizing claims workflows, and ensuring alignment with industry best practices. Leverage knowledge of claims submission, editing, and adjustment processes to scale operations effectively and improve team performance. Maintain up-to-date knowledge of HIPAA, CMS, and state-specific health insurance regulations to guide compliance efforts effectively.
• Cross-Functional Collaboration: Partner with Compliance, Legal, Member Advocacy, Member Claims, Client Success, and Client Issue Resolution teams to resolve escalated issues and contribute to delivering an exceptional member experience.
• Drive Scalability & Process Improvement: Lead quarterly team projects and cross-functional initiatives focused on improving process scalability, enhancing workflows, and driving operational improvements. Apply a scalability lens to optimize resources and capabilities.
• Policy Development & Compliance: Develop and maintain policies and procedures for CX teams, ensuring they align with industry standards and compliance requirements. Continuously evaluate current operations, identify opportunities for improvement, and implement best practices to maintain operational rigor.
• Internal Leadership: Act as a key member of the internal Benefits Council, contributing to the development of Collective Health policies and plan coverage through the review of complex cases.
• Stay Informed: Monitor industry trends, regulatory changes, and current events to ensure the team remains informed and adapts to evolving policies and procedures.
• This role will position you as a leader in driving operational success and fostering cross-functional collaboration to deliver high-quality outcomes for our members and clients.

To be successful in this role, you'll need:

• Leadership and Team Development: You have 8+ years of experience managing teams in claims processing, operations, or a related field, and you’ve consistently met or exceeded expectations in your current role. You are excited about the opportunity to serve as a role model and mentor for a growing team of Team Leaders and associates.  A Bachelor’s degree in Business or Healthcare Administration,  or equivalent experience in the healthcare industry is required.
• Operational Expertise: You bring at least 5 years of auditing medical claims, with  deep knowledge of medical claims processing, medical coding expertise  with a thorough understanding of ICD-10, CPT, HCPC coding systems, Medicare and Commercial Policy payment guidelines, adjudication workflows, and compliance requirements.  You can  demonstrate the  ability to translate operational expertise into effective team practices. You have a solid understanding of medical terminology and disease processes to interpret medical/ claims data accurately.  You have a current CPC, CPC-A,  or CCS designation with broad experience and knowledge of third-party payer practices, including precertification, timely filing, claims processing coverage and payer rules. You also have knowledge of healthcare claims data and analytics, including applicable understanding of federal laws related to ERISA and non-ERISA group health plans.  You have practical knowledge of EDI transaction sets ( such as 835/837, 270/271, etc.). You are familiar with subrogation, coordination of benefits, and claims hierarchy standards.  
• Strong Communication Skills: You are comfortable working with external parties and communicate clearly and concisely, always tailoring your approach to the needs of your audience. You can effectively write and speak to internal and external audiences to clearly articulate your findings and recommendations.
• Problem Solving & Analytical Thinking: You think critically, ask thoughtful questions, and are comfortable challenging the status quo to drive improvements. You have a knack for researching, analyzing, and resolving complex claims or operational issues.  You have the ability to analyze complex medical data, identify patterns, and make informed decisions and recommendations.
• Adaptability & Resilience: You thrive on change and are enthusiastic about navigating and learning from a dynamic, fast-paced environment.
• Attention to Detail: You are highly organized, pay extreme attention to detail, and are adept at managing competing priorities while maintaining high standards of accuracy and timeliness.
• Policy Development & Ambiguity: You enjoy researching, discussing, and developing consistent policies and processes. You’re comfortable working in ambiguous situations and making decisions in the absence of clear answers.

Commitment to Team Success: You are a self-motivated team player who is intellectually curious and takes ownership of your work. You thrive on collaboration and are dedicated to supporting the success of your team and organization.

Pay Transparency Statement 

This is a hybrid position based out of one of our offices: Plano, TX, or Lehi, UT. Hybrid employees are expected to be in the office three days per week (Plano, TX) or two days per week (Lehi, UT). #LI-hybrid 

The actual pay rate offered within the range will depend on factors including geographic location, qualifications, experience, and internal equity. In addition to the salary rate, you will be eligible for stock options and benefits like health insurance, 401k, and paid time off. Learn more about our benefits at https://jobs.collectivehealth.com/benefits/.