Share this Job

Director, Quality Reporting & Configuration

Date: Aug 9, 2019

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans



Position Summary/ Purpose


Under the direction of the Exec. Director of Operations, the Director of Data Quality and Claims Configuration directs the activities of all responsible positions in the Claims System Configuration, Quality Data and Reporting units within the Core Business Systems department. Responsible for claims system configuration and maintenance to ensure efficient and accurate adjudication of claims; accurate claims system and benefits configuration. Responsible for the integrity of data quality and provision of reporting services to dependent departments. Leads technical system integration projects in collaboration with IT and supporting vendors. Collaborate with all other departments to ensure system performance goals are achieved and compliance with Centers for Medicare and Medicaid Services (CMS) and Department of Health Care Services (Medi-Cal and CCI/CMC) guidelines are met.


Major Duties/ Responsibilities


  1. Oversight of the administration, configuration and ongoing maintenance of the claims adjudication system as it relates to claims processing, payment and encounter data accuracy.
  2. Oversight and responsibility for delegated claims functions performed by third party vendor, including configuration services.
  3. Ensures established standards are followed for system configuration processes, including SDLC configuration design, testing and implementation controls, documentation, communication and training best practices.
  4. Directs activites and utilizes Lean methodologies to ensure continuous process improvement.
  5. Through auditing and internal reporting, proactively identify negative or positive trends to data impacted by system configuration and report to management with recommendations for change.
  6. Oversee the claims configuration activities for change management requests, expansions and new business.
  7. Lead ongoing optimizations of the platform, enhancements and projects to improve quality and efficiency.
  8. Direct and oversee the data validation and quality auditing unit and deliverables to support operational, compliance, performance improvement, and business strategy across the organization, with primary support for Core Business Systems and their customers.
  9. Establishes, oversees and ensures internal quality controls to ensure the accuracy of eligibility and claims data configuration.
  10. Directs and overees the quality team in the validation of eligibility and claims data through integrated systems to ensure accuracy for internal and external customers.
  11. Oversee the design and implementation of data analysis activities as appropriate to improve IEHP processes and delivery of care and to meet regulatory reporting requirements with IEHP’s regulatory bodies: DHCS, DMHC, CMS
  12. Establishes partnerships and works closely with the Senior Leadership Team to ensure claims system configuration accuracy; develop plans to address any potential system inaccuracies or configuration errors.
  13. Direct and oversee the reporting team responsible for operational reporting and the coordination of the delivery of dashboards and ad-hoc reporting for business units.
  14. Provide the organization’s leadership team with summarized and current data to be used in making business and strategic decisions to support IEHP in achieving its mission, strategic vision and objectives.
  15. Supports regulatory and internal audits through the provision of data, process documentation and technical specification related to configuration
  16. Work in collaboration with Business Systems unit and IT to assess and maintain the validity and integrity of eligibility and claims configuration impacted data.
  17. Collaborate with IT, and other units to implement strategic initiatives and resolve issues.
  18. Any other duties as required to ensure Health Plan operations are successful.
  19. Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP's policies and procedures relating to HIPAA compliance.


Bachelor's degree required from an accredited four year institution, Master's degree preferred.


Specialized Knowledge/Skills


  1. Strategic thinker with 6+ years of healthcare administration experience, 4+ years in a leadership position. Experience managing health plan data and reporting.  Strong ability to translate data into meaningful and actionable information. This position provides key operational information and key organizational tactical/strategic information through the effective implementation of data initiatives. Initiatives include self-service reporting solutions, data trending analyses, data profiling, data mining, data analysis, and promoting a data-aware culture throughout IEHP.
  2. Must have proficiency in data mining and analysis tools including: Microsoft Access, Excel, word processing, SSRS, SAS, SPSS or other statistical packages. Expertise in data analytics and business intelligence function. 
  3. Knowledge of data visualization and Business Intelligence tools preferred (Tableau, PowerBI).
  4. Demonstrates advanced interpersonal/verbal communication skills.
  5. Ability to analyze information and convert related activities into a comprehensive work plan.
  6. Experience with claims system integrations preferred.
  7. Claims production and configuration experience required.
  8. Knowledge of 837 and 834 files and health plan eligibility preferred.





Starting Salary: $113,464  - $144,622  

Pay rate will commensurate with experience


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles

Find similar jobs: