PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Whittier Hospital, PIH Health Downey Hospital and PIH Health Good Samaritan Hospital, 27 outpatient medical locations, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, women’s health, urgent care and emergency services. The organization is recognized by Watson Health as one of the nation’s Top Hospitals, and College of Healthcare Information Management Executives (CHIME) as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. PIH Health is certified as a Great Place to Work TM. For more information, visit PIHHealth.org or follow us on Facebook, Twitter, or Instagram.

The CLAIMS SUPERVISOR reports to the Director of Claims and is responsible for overseeing and managing the claims examiners, and is responsible for processing claims to ensure accurate and timely claims payment.   The Claims Supervisor understands the types of provider contracting arrangements, and all other fee schedules to support the accurate payment of claims.  The Supervisor  will provide leadership in performance management, identification of performance management of metrics, and one on one mentoring, coaching and ongoing training. The Supervisor will monitor internal controls to ensure proper adjudicatin and payment of claims based on Regulatory guidelines.  This role assists the Director of Claims in operations.

Claims Supervisor is responsible for day to day management of claims inventory, monitoring the production and quality of the staff, mentoring, training, team building and maintaing examiners statistics. The Claims Supervisor will all ensure that all examiners are adhering to guidelines and all organization policies.

Required Skills

• Working  knowledge of medical terminology & RVS/CPT/RBRVS/ICD-10 codes
• Experienced with complex provider contract payment methodologies including but not limited to case-rates and stop-loss.
• Excellent communication, problem solving, and decision-making skills coupled with the ability to work successfully in a team environment.
• Ability to take initiative in analyzing problems, developing solutions and taking necessary action.

Required Experience

• Minimum five (5) years of experience as a senior claims examiner in claims adjudication with knowledge of at least one of the following: membership, benefits, provider contracts & pricing, medical reviews, referral authorizations and code review and fee schedules.
• Knowledge of regulatory requirements (CMS . DMHC and DHS)
• High School Diploma or General Education Development (GED) required.

PREFERRED:

• Associate or Bachelor’s Degree

Beyond the benefits that come with working for the area's leading community healthcare provider – one that also recognizes the need to ensure patient safety and comfort – you'll enjoy an extremely competitive compensation and benefits package.  We are an equal opportunity employer and seek diversity in our workforce.   EOE M/F/D/V

• Working  knowledge of medical terminology & RVS/CPT/RBRVS/ICD-10 codes
• Experienced with complex provider contract payment methodologies including but not limited to case-rates and stop-loss.
• Excellent communication, problem solving, and decision-making skills coupled with the ability to work successfully in a team environment.
• Ability to take initiative in analyzing problems, developing solutions and taking necessary action.