The Claims Supervisor works with Claims Management to oversee the daily operations of the Claims Department. The Claims Operations Supervisor is responsible for the oversight of external as well as internal processes as it relates to claims adjudication. This includes the compilation and scrubbing of claims data to analyze, track, and trend various aspects of the adjudicated claims. This includes but is not limited to, TAT compliance, Production, Error Rate, mid-month reports for forecasting, Health Plan monthly reporting including ODAG and Part C, Health Plan Universes for Audits, reports to identify potential recovery, as well as reports requested by various personnel within the organization. The Claims Operations Supervisor will identify root causes of claims payment errors and reports to Management as well as collaborates with other departments and/or providers in successful resolution of claims related issues. 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. The Supervisor will manage new program implementations and\or system implementation, maintain an up-to date knowledge of national and state-wide standards and regulation pertaining to claims processes and will ensure that production standards meet quality guidelines throughout the claims department ensuring the Plan’s compliance. This position will work with Management and staff to develop procedures ensuring the achievement of goals and will continuously monitor the work performed within the Department.

Responsibility:

• This position has supervisory responsibilities for claims daily operational adjudication and other front and back-end responsibilities and ensures proper and sufficient controls are in place, to ensure all compliance with regulatory processing rules and guidelines.
• Creation of monthly production and error reports as well as to be able to track and trend the most common errors in order to identify areas which require additional training.
• Creation of reports which identify claims that have been overpaid and require refund requests.
• Read and interpret provider contracts to ensure payment/denial accuracy.
• Read and interpret Medi-Cal and Medicare Fee Schedules.
• Oversight of external vendors to ensure processing engines are working daily/weekly as required.
• Work with Claims Management for enhancements to the various rule engines to optimize claims processing.
• Communicate with Claims Management for any issues relating to provider, fee schedule, eligibility, authorization, or system issues.
• Creation of any business rules and training for the Claims Department to become more efficient and accurate.
• Creation of additional exception reports for the Claims Auditing Unit.
• Create scripts to improve auto adjudication.
• Create monthly reports for external vendors for potential TPL and High Dollar Institutional claims.
• Assist Claims Director with the oversight of training material/business rules for Calibrated as well as internal staff.
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers, and customers.
• Attend monthly departmental meetings and provide feedback when requested.
• 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.
• Created, maintain, and monitor departmental documents including desktop procedures, workflow documents and job aids to ensure these documents are current.
• 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.
• Other duties as assigned.

Qualifications:

• HS Diploma or GED required.
• Minimum of 3 years of experience in a managed care environment, claims knowledge required.
• Minimum of 2 years of lead/supervisory experience preferred.
• Experience in working with PDRs preferred.
• Must have experience communicating with eternal providers.
• Must be knowledgeable of Medi-Cal regulations, Commercial, and Medicare rules and regulations.
• Knowledge of medical terminology.
• Must have an understanding to read and interpret DOFRs and Contracts.
• Must have an understanding how to read a CMS-1500 and UB-04 form.
• Must have strong organizational and mathematical skills.

Skills and Abilities:

• HS Diploma or GED required.
• Minimum of 3 years of experience in a managed care environment, claims knowledge required.
• Minimum of 2 years of lead/supervisory experience preferred.
• Experience in working with PDRs preferred.
• Must have experience communicating with eternal providers.
• Must be knowledgeable of Medi-Cal regulations, Commercial, and Medicare rules and regulations.
• Knowledge of medical terminology.
• Must have an understanding to read and interpret DOFRs and Contracts.
• Must have an understanding how to read a CMS-1500 and UB-04 form.
• Must have strong organizational and mathematical skills.

Job Type: Full-time

Pay: $32.00 - $37.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee discount
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Parental leave
• Professional development assistance
• Vision insurance

Schedule:

• 8 hour shift

Ability to commute/relocate:

• Montebello, CA 90640: Reliably commute or planning to relocate before starting work (Preferred)

Work Location: In person

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