SUPERVISOR, CLAIMS

Job Summary:

The Claims Supervisor is responsible for claims processing, knowledge of healthcare regulatory guidelines, computer system functionality, the ability to multi-task, coordinate with customers like health plans and provide accurate data through extensive research skills. This position requires some leadership skills and an ability to provide detailed orientated instructions to staff while assisting them in maintaining and coordinating their daily operational duties.

Responsibilities:

• Plans and assigns work; monitors department workload to ensure mandated turnaround times are met; makes timely and effective adjustments daily, weekly, and monthly.
• Identifies, monitors and analyzes appropriate metrics, including production, inventory and submission/billing patterns; develops timely and effective corrective action plans based on findings.
• Track the inventory prior to check run process by coordinating with the staff to make sure that the process is finalized.
• Oversee provider dispute resolution processes and resolve PDRs as necessary.
• Oversee recovery processes and resolve overpayments as necessary.
• Responds to and resolves or facilitates resolution of complex claims, appeals, provider disputes, and recovery projects.
• Coordinate with all interdepartmental units to improve workflow and processes; identifies issues and opportunities; initiates meetings; resolves issues or makes recommendations as required.

• Distribute work as necessary to the staff daily and weekly.
• Attend meetings on claims related matters that have direct and in-direct relationship to your positions providing an update to the claims management team.
• Attend Claims Operational meetings and participate in the dialogue to provide insight and assist in bringing resolution to open matters.
• Provide direction to staff in the area of claims timeliness guidelines, new rules from governing agencies (CMS & DMHC), and overall claims background.
• Manage the department in meeting and maintaining all Regulatory and Health Care Industry standards.
• Coordinate with all claims staff to ensure that they are collectively networking as a team on all claims matters within the department.
• Identifies training needs and opportunities; develops training plans.
• Assists in the development of departmental goals and tasks to achieve goals.
• Hires, supervises and retains competent staff.
• Writes and delivers performance evaluations and goals to claim staff.
• Regular attendance.
• Travel as required.

Other Functions

• Enforces Company policies and safety procedures.
• Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.
• Maintain IPA, Health Plan compliance standards.

Competencies

• Five (5) years healthcare claims experience, which includes all aspects of claims administration.
• Two (2) years Medi-Cal claims experience.
• Two (2) years supervisory experience.
• Managed care experience preferred.
• In-depth knowledge of regulations and procedures governing Medi-Cal and other state sponsored programs required.
• In-depth knowledge of procedure coding and medical terminology, and their application in benefits; general medical policy benefits and exclusions, and industry standard payment practices required.
• Ability to read, interpret and apply complex written guidelines, instructions and other materials.
• In-depth knowledge of claims processing systems.
• In-depth knowledge of audit processes, and the ability to effectively implement and maintain them.
• Demonstrate ability to articulate and embrace organizational values, integrate into management practices, and enforce implementation among staff.
• Intermediate skills in Word and Excel, including the ability to develop formulas and links.
• Excellent communication skills, including both oral and written.
• Excellent active listening and critical thinking skills.
• Ability to solve advanced level problems with minimal supervision.
• Ability to demonstrate professionalism, confidence, and sincerity while quickly and positively engaging providers.
• Ability to multi-task, exercise excellent time management, and meet multiple deadlines.
• Demonstrate excellence in project management and organization.
• Strong computer skills, including experience with Microsoft Office Suite (Word, PowerPoint, Outlook, and Excel)
• Ability to provide and receive constructive job and/or industry related feedback.
• Ability to maintain confidentiality and appropriately share information on a need to know basis.
• Ability to consistently deliver excellent customer service.
• Excellent attention to detail and ability to document information accurately.
• Ability to effectively and positively work in a dynamic, fast-paced team environment and achieve objectives.
• Ability to demonstrate professionalism, confidence, and sincerity in a diverse work culture.
• Demonstrate commitment to the organization’s mission.
• Must have the ability to quickly learn and use new software tools.
• Must have mid-level skills using e-mail applications.
• Ability to work independently as well as in a team environment.
• Ability to present self in a professional manner and represent the Company image.
• Demonstrate leadership and project success are expected.

Education and Licensure

• High School Diploma or GED minimum requirement.
• BA/BS in Business Management or related field preferred.

Travel

• The incumbent may travel up to 5% of the time.

Supervisor Responsibility

• This position supervises several employees in multiple disciplines: Claims Analysts, Claim Specialist, Eligibility Specialists, and/or Claim Auditors. Up to 12 non-exempt employees.

Work Environment

This job operates in a professional office environment. This role routinely uses office equipment such as computers, phones, photocopiers, scanners and filing cabinets.

Mental and Physical Demands

Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the position. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing this job, the employee is regularly required to talk and hear. The employee frequently is required to sit, stand; walk; use hands to finger, handle, or feel; and reach with hand and arms. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus. Experiences frequent interruptions; required to meet inflexible deadlines; requires concentration and attention to detail; requires a high level of organizational and prioritization skills. May be required to sit for prolonged periods; exposed to visual display terminal for prolonged periods; dexterity and precision required in the operation of a computer.