The Supervisor, Claims Audit is responsible for overseeing and managing claims auditors/trainers and ensuring that all policies and procedures are enforced as it relates to health plans and regulatory agencies requirements. This role understands claims payments/processes, compliance, audits, policies and procedures, state and federal regulations, health plan contracts, provider contracts, reimbursement, and audits. Will provide leadership in performance management of claims audits and training. Reports to the Director of Claims. Responsible for the day-to-day management of claims audits, and training of claims examiners. Will ensure that all claims examiners are fully trained and equipped to meet or exceed their productivity, process claims in accordance with contracted and non-contracted providers, and meet health plans’ and regulatory agencies’ requirements.

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 Downey Hospital, PIH Health Good Samaritan Hospital, PIH Health Whittier Hospital, 37 outpatient medical office buildings, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, digestive health, orthopedics, women’s health, urgent care and emergency services. The organization is nationally recognized for excellence in patient care and patient experience, and the College of Healthcare Information Management Executives (CHIME) has identified PIH Health as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology.

Required Skills

• Experience in processing professional (CMS-1500) and institutional claims (UB04)
• Expert in HCPCS/CPT codes, ICD-10s, RBRVS, etc.
• Excellent oral and written communication skills
• Ability to train, coach, and mentor staff
• Knowledgeable in provider contracts and health plan agreements
• Experience paying, denying, and processing claims
• Knowledgeable in commercial, Medicare, and Medi-Cal reimbursement methodologies (i.e. fee schedules, OPPS, MS-DRG, etc.)
• Knowledgeable in eligibility, benefits, evidence of coverage, EOB, and remittance advise
• Able to work well with all levels of management
• Excellent problem-solving skills, decision-making skills, and analytical skills coupled with the ability to work successfully in a team environment.
• Ability to take initiative in identifying problems, developing solutions, and taking the necessary action to resolve the problems.

· Fully developed skills in the following areas required: claims production, claims audit, claims adjudication process, physician billing/coding, contracts analysis, customer/member service, personal computer (spreadsheet, database, word processor), and effective communication and presentation skills

· Has full knowledge of all regulatory requirements from CMS, DMHC and DHS

· Thorough understanding of reimbursement methodologies as they relate to managed care contracting

Required Experience

Required:

· Minimum five years’ experience in managed care and supervising

Preferred:

· Bachelor's degree in one of the following areas: Business Administration, Accounting, Finance or Healthcare Management

• Experience in processing professional (CMS-1500) and institutional claims (UB04)
• Expert in HCPCS/CPT codes, ICD-10s, RBRVS, etc.
• Excellent oral and written communication skills
• Ability to train, coach, and mentor staff
• Knowledgeable in provider contracts and health plan agreements
• Experience paying, denying, and processing claims
• Knowledgeable in commercial, Medicare, and Medi-Cal reimbursement methodologies (i.e. fee schedules, OPPS, MS-DRG, etc.)
• Knowledgeable in eligibility, benefits, evidence of coverage, EOB, and remittance advise
• Able to work well with all levels of management
• Excellent problem-solving skills, decision-making skills, and analytical skills coupled with the ability to work successfully in a team environment.
• Ability to take initiative in identifying problems, developing solutions, and taking the necessary action to resolve the problems.

· Fully developed skills in the following areas required: claims production, claims audit, claims adjudication process, physician billing/coding, contracts analysis, customer/member service, personal computer (spreadsheet, database, word processor), and effective communication and presentation skills

· Has full knowledge of all regulatory requirements from CMS, DMHC and DHS

· Thorough understanding of reimbursement methodologies as they relate to managed care contracting