Director, Claim Payment Accuracy

Strategic Policy & Oversight:

• Own the accountability for the development and maintenance of clinical and reimbursement policies.
• Ensure perfect alignment with CMS regulations.
• Achieve flawless adjudication.

Global Quality Audit Framework:

• Design and oversee a multi-layered audit program.
• Monitor adjudication system output against clinical policies, pricing, benefit rules, and provider contract terms.
• Ensure all findings feed into a continuous improvement loop.

AI-Driven Evolution:

• Lead the implementation of AI initiatives to automate monitoring.
• Independently utilize LLMs to analyze oversight trends.
• Develop data-driven criteria for judgmental sampling and targeted audits.