Supervisor - Claims Operations

What You'll Do

• Monitor and review work of all Claims production staff to identify additional training needs and to ensure compliance with department quality and production standards. Provide performance feedback and identify developmental opportunities for Claims staff.
• Monitor and review claims production and transaction reports. Identify claims error trends and implement controls and changes that will minimize incorrect claims adjudication. Coordinate potential recovery efforts with Company Accounting and coordinate potential physician education opportunities with Company Physician Services.
• Work closely with other Company departments to ensure that all areas supporting claims meet appropriate claims quality goals.
• Ensure that all legal, regulatory, and policy requirements are met by keeping informed of changes and implementing necessary controls and/or programs to meet requirements.
• Manage and update claims production policies, workflows, and processes to ensure compliance with Claims department and State, Federal, and Health Plan quality standards. Provide analysis of claims quality adjudication results and identify training opportunities for the Claims team.
• In collaboration with the Claims QA and Training Specialist, Supervisor, ensure that Claims Representatives have a thorough understanding of Company claims adjudication policies and procedures.
• Coordinate provider contract, health plan benefit/DOFR, and system rules configuration testing with the Business Applications Configuration team.
• Ensure accurate reporting and timely submission of quarterly PDR timeliness reports.
• Prepare, coordinate, and facilitate external party PDR and adjustment audits. Develop any corrective action plans (CAPs) that result from PDR and adjustment audit findings, and monitor progress and application of documented CAPs.
• Work with Company departments on implementing controls to minimize claims overpayments and identify physician education opportunities with Network Management.
• Work closely with other Company departments and specifically the Claims QA and Training Specialist to communicate findings of recovery audits and to facilitate accurate adjudication of claims.
• Supervise direct reports by assigning and directing work; conducting employee evaluations, staff training, and development; taking appropriate disciplinary/corrective actions; and making hiring/termination recommendations. Mentor team members in both technical and functional areas to provide growth opportunities.
• Accountable for achieving departmental goals related to claims inventory, turnaround times, quality scores, production standards, and financial accuracy.
• Other duties as assigned.

Qualifications

• Bachelor’s degree in a relevant field (or an equivalent combination of education and progressively responsible experience).

• At least 5 years of medical claims experience with a Medical Group, IPA, MSO, or Health Plan.
• At least 2 years of lead, supervisory, or people leadership experience preferred.
• Experience must be in healthcare claims; experience in workers’ compensation, life insurance, or auto insurance does not count toward the minimum requirement.

• Advanced knowledge of and hands-on experience with healthcare coding conventions, including ICD-10, CPT, and HCPCS.
• Thorough knowledge of medical claim processing procedures and systems, including auditing, claim protocols, industry standards, and CMS regulations related to claims payment and compliance.
• Advanced knowledge of claims processing system configuration and architecture sufficient to troubleshoot complex claims transaction issues.

Environmental Job Requirements and Working Conditions

• Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Drive, Monterey Park, CA 91754.
• The total compensation target pay range for this role is between $78,000 - $91,000. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.