Claims Quality Compliance Manager

Brentwood, TN, USA Req #43
Thursday, October 22, 2020

Job Summary:

The Claims Quality Compliance Manager is responsible for the supervision of claims quality compliance, appeal, dispute, and reconsideration activities and direct report staff.  The Manager ensures all daily claim audit and claim appeal related activities are performed at the highest level or quality, timeliness and that all Service Level Agreements and performance guarantees are successfully met.



  • Utilizes expertise to determine accuracy and appropriateness of claim appeals, disputes reconsiderations, quality compliance, and departmental practices.
  • Relies on extensive experience and judgment to plan and accomplish department objectives.
  • Evaluates provider billing appropriateness, standard fee for service and Medicare episodic contract concepts, and claim billing practices looking for potential fraud, waste, and abuse.
  • Guides Claims Quality Assurance Specialist, Quality Appeals Specialist, and Clinical Claim Review to meet and exceed department quality and compliance goals.  Also, directs staff to meet and exceed daily, weekly, and monthly role specific production standards.
  • Escalates quality issues to departmental leader and Company Compliance Officer timely.
  • Concentrates on improving claims payment accuracy and decreasing processing cost per claim and cost per submitted claim appeals, disputes, or reconsideration.
  • Identifies potential quality risks and implements appropriate courses of action.
  • Leads quality project implementations for existing and new clients for the Claims Department.
  • Works with the Claims Manager to deliver process, procedure, and systemic training opportunities and efficiencies to support claims examiner processing team members.
  • Manages and resolves claim appeal, dispute, and reconsideration case inventory with determination to meet established client service level agreements and performance guarantees.



Professional Responsibilities:

  • Adheres to dress code, appearance is neat and clean.
  • Reports to work on time and as scheduled completing work within designated time.
  • Follows all company policies related to time records.
  • Attends annual review and department in-services, as scheduled.
  • Leads departmental staff meetings as scheduled and covers company and departmental updates using technology when and where necessary to convene examples and illustrations of relevant topics as requested.
  • Represents the organization in a positive and professional manner.
  • Actively participates in performance improvement and continuous quality improvement (CQI) activities for Department and the Company.
  • Complies with all organizational policies regarding ethical business practices.
  • Communicates and demonstrates the mission, ethics and goals of the facility, as well as the focus statement of the department.


Required Skills/Abilities:

  • Excellent written and oral communication skills.
  • Ability to read and communicate effectively in English.
  • Additional languages preferred.
  • Intermediate level computer knowledge of Microsoft Office including Word, Power Point, and Excel.
  • Intermediate level fluency in Microsoft Excel with proven capability to manage and perform spreadsheet manipulation using functions, formulas, and analysis within the program.
  • Remote workforce management.
  • Basic mathematical knowledge.
  • Excellent client customer service, client presentation, and follow-up skills.
  • Strong organizational and leadership skills to cross collaborate between different departments.
  • The ability to manage multiple projects at one time.
  • Analytical, strategic minded and goal oriented. 
  • A leader with the ability to work independently.
  • Ability to sit for extended periods and read multiple monitors.
  • Strong attention to detail.



Education and Experience:

  • Bachelor’s Degree.
  • Knowledge of medical terminology, health insurance plans, medical billing concepts, health care quality and compliance for health insurance payer companies.
  • Minimum of five (5) years of experience in medical claims processing, quality compliance, provider claim appeals, grievances, reconsiderations, and other provider correspondence for Medicare Advantage, Medicare Part C plans and Traditional Medicare FFS fee for service.
  • Home health claims processing and home health care billing operations experience.
  • Previous experience in a production environment utilizing technology platforms to deliver daily work.
  • Minimum of three (3) years of personnel management leading production driven teams in a health care services company environment with an emphasis on managing a multidisciplinary, remote work force.


Other details

  • Pay Type Salary
  • Brentwood, TN, USA