Director Managed Care Quality in Virtual / Travel

$200K - $250K(Ladders Estimates)

Sedwick   •  

Virtual / Travel

Industry: Finance & Insurance

  •  

8 - 10 years

Posted 55 days ago

PRIMARY PURPOSE:

To focus on trends and quality compliance; to lead and develop organizational quality initiatives; to recommend and develop audit tools, service level agreements and training needs for operational and functional units; and to plan and initiate appropriate actions facilitating overall office performance, development and improvement.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

  • Presents audit findings and results to local, regional and national management.
  • Leads and develops organizational initiatives and goals (i.e. penalty reduction, error and omission mitigation, national improvement, predictive analytics).
  • Supervises a team of jurisdictional auditors.
  • Assists operations in coordinating and implementing national quality initiatives at the local level.
  • Interfaces with key partners, including operations, clients, and carriers.
  • Responsible for the development of service expectations including researching, authoring, and dictating the auditable steps for all positions within Casualty Operations, Disability Operations, Clinical Operations, Professional Liability Operations, Specialty Operations, Program Management and Implementation.
  • Responsible for carrier audit activities including coordinating and prepping the Company's response to carrier audits, coordinating the rebuttal process to ensure the opportunity to state the Company's position with a carrier who has come to a different conclusion on claim handling than our own, and managing the field office compliance with action plans were dictated by poor audit results.
  • Responsible for carrier interaction with respect to carrier score carding and conducting the specific audits that comprise our company's overall scorecard results with those carriers.
  • Responsible for the creation and ongoing maintenance of the actual audit questions that are derived from our service expectations to ensure we stay in close calibration with all of our constituents' needs an interests including clients, carriers, brokers and jurisdictional requirements in each of the state for which we adjudicate claims.
  • Responsible for having multi-line expertise with the ability to audit, trouble-shoot and provide guidance in more than one line of coverage.
  • Responsible for corporate level auditing to ensure SO1 field compliance in key control areas of claims handling.
  • Provides backup for the chief performance officer as needed.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

  • Performs other duties as assigned.
  • Supports the organization's quality program(s).
  • Travels as required.

SUPERVISORY RESPONSIBILITIES

  • Administers company personnel policies in all areas and follows company staffing standards and training recommendations.
  • Interviews, hires and establishes colleague performance development plans; conducts colleague performance discussions.
  • Provides support, guidance, leadership and motivation to promote maximum performance.

QUALIFICATIONS

Education & Licensing
Bachelor's degree from an accredited college or university preferred.
Professional certification such as AIC, CPCU or ARM preferred.
Certified Case Manager (CCM) preferred.
Experience
Ten (10) years of claims management experience or equivalent combination of education and experience required. Two (2) years of service with the company preferred.
Skills & Knowledge
  • Thorough knowledge of claims management practices and procedures
  • Strong understanding of quality and auditing processes
  • Good adult learning skills
  • Excellent oral and written communication skills, including presentation skills
  • PC literate, including Microsoft Office products
  • Leadership/management/motivational skills
  • Analytical and interpretive skills
  • Strong organizational skills
  • Excellent interpersonal skills
  • Excellent negotiation skills
  • Ability to work in a team environment
  • Ability to meet or exceed Performance Competencies


Valid Through: 2019-9-17