This position will report directly to the AVP of Claims Quality, Compliance and Training within the Claims Shared Services organization. This high profile position will collaborate to build a program to direct claims-wide regulatory compliance activities and quality oversight for all lines of business. Provides Senior Management with analysis and recommendations to operationalize compliance requirements and improve quality. Accountable for streamlining processes to manage day to day regulatory support and provides oversight and governance for all claims compliance initiatives. Partners to evolve the quality program to an outcome-driven methodology with root cause analysis reporting and financial quantification. Unit will measure the adherence to regulatory requirements and internal quality processes and procedures through routine testing. Builds strong relationships with Claims Operations and Field, Corporate Compliance, Internal Audit, and other areas across the Enterprise to monitor and promote regulatory compliance and quality performance. Responsibilities may include representing the Claims organization to External Auditors, State Regulators, and internal Lines of Defense partners.
The Director of Claims Quality and Compliance will lead a diverse workgroup focused on driving regulatory compliance and quality improvement across the organization. The responsibilities of the position include:
- Management for direct reports to include building a high performing team of technical experts, strategic thinkers, and strong influencers to manage and promote quality and compliance.
- Oversees a team who measure, analyze and report on quality and compliance audits.
- Partners with Corporate Compliance and Claims Operations and Field to manage regulatory examinations and facilitates the development and execution of tactical and strategic action plans.
- Responsible for partnering with IT and vendors to facilitate claim data governance relating to reporting requirements for: Medicare reporting, EDI reporting, data calls, and other regulatory requirements.
- Acts as the subject matter expert for the Claim organization to ensure understanding and compliance with applicable state, federal and other regulatory requirements. Stays ahead of changing obligations, emerging issues, and educates business partners.
- Interacts regularly with internal stakeholders such as Claims, Corporate Compliance, Internal Audit and other functional areas to ensure Claim operational activities remain in compliance with applicable laws and regulations and meet business goals.
- In partnership with Claims Training, designs, develops, and maintains learning objectives to promote quality and compliance.
- Develops annual testing plan to measure and monitor quality and compliance performance.
- Partners with Claim leaders to continuously improve performance and develop meaningful action plans. Assist with issue identification and oversight.
- Sets KPIs and KRIs to measure the health of quality and compliance and delivers value added first-line reporting to Senior Leadership.
- Communicates with frontline leadership regarding the importance of regulatory compliance and quality initiatives to promote a strong culture and improve organizational health.
- In depth knowledge of the insurance industry, its practices and operations; technical expertise in related regulatory compliance and operational quality oversight. Preferable background in P&C and/or Workers' Compensation.
- Ability to effectively lead, coach and motivate a team to grow and deliver stated objectives.
- Ability to exercise professional judgment and assume responsibility for decisions which have an impact on business goals, people and expense.
- Ability to effectively interact and build trusting and collaborative partnerships quickly with all levels of internal and external business partners within scope of responsibility, team and/or matrix environment.
- Ability to operate in an iterative, agile environment with strong cross-discipline team collaboration.
- Excellent written and verbal communication and presentation skills, including the ability to communicate business and technical information effectively.
- Excellent analytical and problem solving skills. Demonstrated creativity in resolving unique and challenging business problems.
- Ability to drive and achieve results, with ability to manage multiple projects to meet both short and long-range goals and objectives. Includes strong project management skills.
- Strong computer skills including Microsoft Office Suite and other business related software systems.
- Advocate for change and ability to influence and champion a new way of working.
Education & Experience
- Bachelor's degree with Master's degree preferred in a related discipline (such as Risk Management, Law degree) or equivalent.
- Typically, a minimum of 10 years of related claims management experience, with 3+ years recent and direct regulatory compliance/quality leadership experience.
- 5+ years in claims auditing, compliance testing, or related experience.
- Experience working with Departments of Insurance and other regulatory bodies preferred.
- Applicable risk and compliance designations preferred (i.e. ARM, CRCMP, ARC or IRES designation) desirable.
- Applicable Quality certifications through a reputable organization (i.e. ASQ, IIA) desirable.
- Familiar with industry-related regulatory software products (i.e. MetricStream, Bwise, Wolters Kluwer) and auditing platforms (i.e. TeamThink).
- Experience with analyzing state and local laws to instrument solutions to operationalize compliance.