Claims Supervisor

A reasonable salary expectation is between $71,572.80 and $82,305.60, based upon experience and internal equity.

Position Summary/Position

The Medical Claims Supervisor provides daily oversight of claims staff, business processes and inventory management. Ensures the claims team follows state/federal regulations and standard operating procedures. Develops best practices to optimize claim processing quality. Evaluates professional skills of team members and provide appropriate work assignments. Resolve claim payment issues and quality oversight. Assist in hiring and training new team members in their job responsibilities. Monitors individual and team performance to ensure quality and performance objectives are met. Assist in employee performance evaluation, coaching and professional development activities to imp

rove performance efficiency.

Major Functions (Duties and Responsibilities)

1. Coordinate day-to-day claims operations tasks in accordance with established policies and procedures, standard operating procedures, and job aids to ensure optimal performance results.

2. Monitor and track claim inventory / workflow through the entire claim life cycle to ensure timely processing of claims based on regulatory and contractual compliance requirements.

3. Oversight of all aspects of departmental monitoring tools and controls to promote operational excellence.

4. Responsible for driving team results based upon established departmental quality and production performance metrics.

5. In collaboration with the Claims Quality Assurance and Training teams, review audit results to evaluate opportunities for staff development, training, and remediation needs to maximize claim outcomes.

6. Develop strategies to improve upon departmental effectiveness and efficiencies. Identifies and implements process improvement opportunities that focus on customer value.

7. Serve as a subject matter expert and liaison with internal and external customers to address claim issues in an expeditious, accurate method.

8. Assist in formulating and executing initiatives to achieve departmental goals and objectives.

9. Select and build strong, professional functional teams through training reinforcement, coaching, motivation, and performance management. Complete and track effective performance evaluations and maintain ongoing dialogue with team members regarding development opportunities.

10. Assist Claims Management in identifying, creating, and implementing policies and procedures, standard operating procedures, and desk top references.

11. Make recommendations to leadership on changes and additions to department procedures through innovative thinking with an emphasis on automation.

12. Stay current with changes mandated by the regulatory agencies and industry standard processes.

13. Attend key strategic meetings that are necessary to maintain a viable knowledge base within IEHP. Initiate and conduct internal meetings as well as adding substance to discussions, sharing new ideas, personal perspectives, and provides relevant follow-up items.

14. Serves as a support to the Claim Operations Manager for absences, spike claim receipts, etc.

Experience Qualifications

Four (4) years claims processing experience. At least two (2) years experience in a supervisory capacity. Three (3) years experience in a managed care environment. Experienced in benefit and financial matrix interpretation.

Preferred Experience

Experience preferably in an HMO or Managed Care setting. Medicare and/or Medi-Cal experience preferred. Prior experience in a lead role or customer service environment is a plus.

Education Qualifications

High School diploma or GED required.

Knowledge Requirement

Knowledgeable in CMS, DHMC and DHCS regulatory guidelines. Extensive knowledge of ICD-9, ICD-10, CPT, and Revenue Codes. Solid understanding of the DHCS, CMS rules and regulations governing claims adjudication practices and procedures desired. Principles and techniques of supervision and training.

Work Model Location

Telecommute