Supervisor, Claims

Job Summary

The Claims Supervisor works with the Claims Manager to oversee the daily operations of the claims department. This position is responsible for ensuring that quality levels of performance are maintained throughout the Claims Department and that all functions remain in compliance with State and Federal regulations. This position will  manage new program implementations and/or system implementations. This position must maintain an up-to date knowledge of national and state-wide standards and regulations pertaining to claims processes and will ensure that production standards meet quality guidelines are met throughout the department ensuring the Plan’s compliance. This position will work with  department Supervisors and staff to develop procedures ensuring the achievement of goals and will continuously monitor the work performed within the Department.

The position supervises all aspects of running an efficient  team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. 

Duties

Provide an environment that allows staff members to flourish in their work duties. Quality levels of 99% maintained throughout the department. Continuous training of supervisors on supervisory responsibilities as well as staff training on all enhancements and updates to claims regulations and company policies. Develop procedure changes to improve results. Corrective action plans developed and implemented to remediate any shortcomings in goal achievement.

Maintain quality goals and production levels within the Department. Ensure that Claims Department Supervisors are working effectively with their staff to ensure quality and production goals associated with each work area are consistently met by staff during their regularly scheduled work hours.

Create, maintain and monitor departmental documents including policies, procedures, desktop procedures, workflow documents and job aids to ensure these documents are current and meet the requirements of L.A. Care.

Track and trend the metrics associated with the claims adjudication. Prepare and present written and verbal reports. Research complex problem areas within the department or within the systems used by department, and identify the root cause of these issues and recommend corrective actions.

Supervise staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.

Perform other duties as assigned. 

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 3 years of experience as claims examiner working with medical facility claims and high dollar claims.

At least 2 years of leading process, program, or staff or supervisory experience.

Equivalency:  Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.

Experienced in working with Provider Dispute Resolution (PDR's).

Must have extensive experience in handling claims appeals with experience in communicating with external providers.

Skills

Required:
Sound understanding of health care code sets including Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), ICD-10 and revenue codes required.  

Familiarity with Diagnosis Related Group (DRG) pricing.

Ability to multi-task in a high production environment. 

Familiarity in working with and interpreting Provider and facility contracts and  LOA's and MOU's.     

Ability to draw conclusions from data analysis and to formulate corrective action plans when necessary.   

Proficient in using Microsoft  Word and Excel. 

Must have strong coaching and mentoring skills and have the ability to build effective teams.  

Must have excellent written and verbal communication skills with ability to work effectively with diverse team members. 

Ability to research complex claims problems and to create clear and concise procedures for the handling of complex claims.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information