Supervisor, Claims Integrity Recovery Services

Job Summary

The Supervisor, Claims Integrity & Recovery Services, leads a team responsible for identifying, preventing, and recovering inappropriate claim payments across the organization. This position oversees day-to-day operations for pre- and post-payment claims review, overpayment identification, recovery execution, and related provider/member outreach. The Supervisor ensures work is timely, accurate, compliant, and aligned with contract terms, regulatory requirements, and internal policies while driving operational efficiency, quality outcomes, and strong collaboration with internal stakeholders.

This position will work with the department senior management and staff to develop procedures ensuring the achievement of goals and will continuously monitor the work performed within the department.

The Supervisor is responsible for supervising daily operations that include setting goals, evaluating performance and addressing issues.  Supervision of staff includes but is not limited to monitoring day-to-day activities of staff, creating schedules, manages PTO requests, provides guidance and feedback to staff on performance, mentoring, training, and cross-training of staff, addressing questions or issues raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.

The Supervisor ensures the team's efforts align with organizational goals and objectives.

Duties

Oversee review of claim payments to detect overpayments, duplicate payments, coordination of benefits (COB) issues, clinical editing/payment policy errors, pricing discrepancies, eligibility/benefit errors, and contract/payment misconfiguration impacts. Partner with Claims Operations and Configuration to resolve root causes and prevent recurrence.  Escalate potential fraud, waste, or abusive billing patterns to SIU/Program Integrity by established referral criteria.

Manage recovery activities such as offsets/withholds, demand letters, recoupments, refund processing, and coordination with Accounts Payable/Finance.  Ensure accurate calculation, tracking, and reconciliation of recoveries; support month-end reporting and audits. Coordinate with internal and external stakeholders on recovery disputes, contract interpretation, and provider education.

Maintain compliance with applicable state/federal requirements, Centers for Medicare and Medicaid Services (CMS) guidance, and internal policies. Implement and monitor quality assurance programs.  Support internal/external audits, regulatory inquiries, and ad-hoc data requests with well-organized case files and evidence.

Track and report key performance indicator (KPIs). Use data to identify process opportunities and improvements to improve recovery yield and prevent improper payments. Contribute to standard operating procedures (SOP) updates, training materials, and standardization across lines of business. 

Serve as an escalation point for complex cases involving multiple systems, providers, or lines of business (LOB).

Collaborate with Appeals/Grievances on disputes; ensure documentation meets requirements.

Coordinate with cross-functional teams when recoveries require clinical review or medical record validation. 

Responsible for addressing issues, resolve disputes, and ensure compliance with policies and procedures.

Supervises the day-to-day operations of the department.  Responsible for creating the schedules for assigned staff and training new team members. Provide ongoing development opportunities for their assigned staff.

Assist and recommend in the establishment of performance goals, communicating to the assigned staff.  Ensure teams comply with organizational and regulatory standards.

Responsible for allocating resources effectively and ensuring optimal utilization

Responsible for administrative work, including reporting, budgeting, and policy implementation.

Perform other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 3 years of experience processing Health Plan claims recoveries in a managed care environment.

At least 1 year of experience in leading a process, program, or staff or supervisory role.

Experience with recovery tools/case management platforms and claims systems (e.g., Facets, QNXT, HealthRules, EPIC Tapestry, or similar).

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

Skills

Required:

Ability to effectively prioritize and meet deadlines while managing multiple competing tasks.

Ability to multi-task in a high production environment.

Strong analytical skills: Ability to draw conclusions from data analysis and formulate corrective action plans when necessary.

Knowledge of Microsoft Office suite, including Word, Excel and PowerPoint

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

Ability to research complex recovery posting problems and create clear and concise procedures for the handling of complex recoveries.

Solid understanding of standard claims processing systems and claims data analysis.

Healthcare data knowledge.

Familiarity with regulatory requirements for overpayment recovery and notice/appeals processes for the applicable programs.

Knowledge of CPT/HCPCS/ICD-10, modifiers, place of service, and billing/provider reimbursement concepts.

Skilled in leading, mentoring, and developing staff.

Proficient in overseeing operations and managing resources.

Ability to plan and make decisions that align with organizational goals.

Proficient skills in leading, mentoring, and developing staff.

Skilled in handling paperwork, budgets, and reports.

Proficient understanding of organizational policies and procedures and regulatory policies and guidelines.

Skilled in leading, mentoring, and developing staff.

Strong ability to communicate, conflict resolution, and motivational skills.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information