Director of Claim Payment Accuracy

Job Summary

Leading the charge for claim payment precision, the remote Director of Claim Payment Accuracy will architect strategic roadmaps, oversee quality audits, and implement AI initiatives to enhance payment outcomes within a Medicare Advantage framework.

Key responsibilities:

• Own the development and maintenance of clinical and reimbursement policies, ensuring compliance with CMS regulations
• Design and oversee a multi-layered audit program to monitor adjudication system outputs against established policies and contracts
• Lead the implementation of AI initiatives to automate monitoring and enhance the accuracy of reimbursement policies

Required qualifications:

• 8+ years of leadership experience in healthcare claims, payment accuracy, or policy oversight, particularly in Medicare Advantage
• Expertise in HealthEdge HRP and Source systems, with a focus on adjudication accuracy
• Strong background in applying AI technologies and LLMs to operational precision
• Proven ability to navigate complex cross-functional relationships to drive systemic change
• Experience in overseeing vendor relationships at a strategic level to ensure performance standards are met