Under general supervision, the Claims Supervisor is responsible for providing oversight and coordinating the daily operations of claims production, or claims adjustment and auditing functions in a manner that meets established turnaround, quality and production goals, and regulatory standards. Work is varied and minimally to moderately complex, and requires a limited to moderate degree of discretion and independent judgment.

SUPERVISES

• Claims Analysts

ESSENTIAL FUNCTIONS

• Plans and assigns work; monitors department workload to ensure mandated turnaround times are met; makes timely and effective adjustments.
• Identifies, monitors and analyzes appropriate metrics, including production, inventory and submission/billing patterns; develops timely and effective corrective action plans based on findings.
• Develops, implements and maintains department policies and procedures; makes recommendations for revisions; communicates changes to appropriate individuals in a timely and effective manner.
• Responds to and resolves or facilitates resolution of complex claims, appeals, provider disputes, and third party liability cases.
• Assists with the development and implementation of department-related upgrades and enhancements of transaction system and other tools.
• Identifies, monitors and analyzes transaction system processing issues; corrects or escalates as required.
• Works closely with interdepartmental units to improve workflow and processes: identifies issues and opportunities; initiates meetings; resolves issues or makes recommendations as required.
• Prepares for and participates in regulatory audits: compiles audit packets, provides information, develops and monitors timely and effective corrective action plans.
• Executes and monitors business plans; assists in the development and monitoring of department budget.
• Identifies training needs and opportunities; develops and delivers routine and ad hoc department training.
• Promotes and maintains an environment that supports HPSJ’s strategy, vision, mission and values.
• Hires, supervises and retains a competent staff.

NON-ESSENTIAL FUNCTIONS

• Assists in developing department objectives and business plans.
• Other duties as required.

Required Skills

• In-depth knowledge of: procedure coding and medical terminology, and their application in benefits; general medical policy benefits and exclusions; industry standard payment practices.

• In-depth knowledge of claims processing systems, including coding.

• Basic knowledge of claims administration metrics models.

• Basic knowledge of audit processes, and the ability to effectively implement and maintain them.

• Ability to read, interpret and apply complex written guidelines, instructions and other materials.

• Ability to develop, execute and monitor relevant business plans.

• Basic analytical skills.

• Decision quality: Makes good and timely decisions that keep the organization moving forward.

• Action oriented: Takes on new opportunities and tough challenges with a sense of urgency, high energy and enthusiasm.

• Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.

• Directs work: Provides direction, delegates and removes obstacles to get work done.

• Plans and aligns: Plans and prioritizes work to meet commitments aligned with organization goals.

• Optimizes work processes: Knows the most effective and efficient process to get things done, with a focus on continuous improvement; can develop, implement and maintain processes.

• Ensures accountability: Holds self and others accountable to meet commitments.

• Drives results: Consistently achieves results, even under tough circumstances.

• Organizational savvy: Maneuvers comfortably through complex policy, process and people-related organizational dynamics.

• Being resilient: Rebounds from setbacks and adversity when facing difficult situations.

• Courage: Steps up to address difficult issues, says what needs to be said.

• Situational adaptability: Adapts approach and demeanor in real time to match the shifting demands of different situations.

• Strong oral and written communication skills with the ability to communicate with diverse individuals inside and outside of HPSJ.

• Good presentation skills.

• Strong facilitation, problem solving and conflict resolution skills.

• Strong interpersonal skills with the ability to maintain effective working relationships with diverse individuals inside and outside of HPSJ

• Ability to commit to and facilitate an atmosphere of collaboration and team work.

• Strong customer service skills.

• Demonstrated ability to articulate and support HPSJ’s vision, mission, values and strategy, integrate into management practices, and foster their manifestation among staff.

• Demonstrated ability to supervise staff in a manner that maximizes employee performance and business results.

• Ability to develop and deliver relevant and effective training and supporting materials.

• Intermediate skills in Word and Excel, including the ability to develop formulas and links.

• Basic mathematics skills.

• Ability to speak and be understood in English.

• Ability to handle confidential information with appropriate discretion.

Preferred

• In-depth knowledge of regulations and procedures governing MediCal and other state sponsored programs.
• In-depth knowledge of the principles and practices of managed care.

Required Experience

• HS diploma.
• At least one year experience as a claims supervisor in healthcare; or
• At least two years experience as a claims lead in healthcare; or
• At least four years progressively responsible experience in healthcare claims.

Preferred

• Associate’s Degree.
• Managed care experience.

LICENSES, CERTIFICATIONS

Required

• Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability.

• In-depth knowledge of: procedure coding and medical terminology, and their application in benefits; general medical policy benefits and exclusions; industry standard payment practices.

• In-depth knowledge of claims processing systems, including coding.

• Basic knowledge of claims administration metrics models.

• Basic knowledge of audit processes, and the ability to effectively implement and maintain them.

• Ability to read, interpret and apply complex written guidelines, instructions and other materials.

• Ability to develop, execute and monitor relevant business plans.

• Basic analytical skills.

• Decision quality: Makes good and timely decisions that keep the organization moving forward.

• Action oriented: Takes on new opportunities and tough challenges with a sense of urgency, high energy and enthusiasm.

• Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.

• Directs work: Provides direction, delegates and removes obstacles to get work done.

• Plans and aligns: Plans and prioritizes work to meet commitments aligned with organization goals.

• Optimizes work processes: Knows the most effective and efficient process to get things done, with a focus on continuous improvement; can develop, implement and maintain processes.

• Ensures accountability: Holds self and others accountable to meet commitments.

• Drives results: Consistently achieves results, even under tough circumstances.

• Organizational savvy: Maneuvers comfortably through complex policy, process and people-related organizational dynamics.

• Being resilient: Rebounds from setbacks and adversity when facing difficult situations.

• Courage: Steps up to address difficult issues, says what needs to be said.

• Situational adaptability: Adapts approach and demeanor in real time to match the shifting demands of different situations.

• Strong oral and written communication skills with the ability to communicate with diverse individuals inside and outside of HPSJ.

• Good presentation skills.

• Strong facilitation, problem solving and conflict resolution skills.

• Strong interpersonal skills with the ability to maintain effective working relationships with diverse individuals inside and outside of HPSJ

• Ability to commit to and facilitate an atmosphere of collaboration and team work.

• Strong customer service skills.

• Demonstrated ability to articulate and support HPSJ’s vision, mission, values and strategy, integrate into management practices, and foster their manifestation among staff.

• Demonstrated ability to supervise staff in a manner that maximizes employee performance and business results.

• Ability to develop and deliver relevant and effective training and supporting materials.

• Intermediate skills in Word and Excel, including the ability to develop formulas and links.

• Basic mathematics skills.

• Ability to speak and be understood in English.

• Ability to handle confidential information with appropriate discretion.

Preferred

• In-depth knowledge of regulations and procedures governing MediCal and other state sponsored programs.
• In-depth knowledge of the principles and practices of managed care.