The Claims Operational Support Supervisor oversees the day-to-day operations of the operational support staff, which includes the Recovery and Provider Dispute Resolution (PDR) teams. This position is responsible for following regulatory and internal guidelines in conjunction with CalOptima policies and procedures as they apply to claims operation support for Medi-Cal and Medicare (OneCare and OneCare Connect), and PACE.
POSITION RESPONSIBILITIES:
- Trains and supervises all operational support employees to ensure adherence to the Medi-Cal and Medicare regulatory and processing guidelines. Identifies any new learning opportunities for staff (i.e. new desktops, recovery opportunities, provider education opportunities).
- Maintains presence at workshops related to claims guidelines in order to allocate and guide staff.
- Monitors and actively pursues recovery opportunities in accordance with regulatory standards; identifies new opportunities and makes recommendations.
- Reviews and actively participates in education and identification of potential fraud and abuse related to claims submissions through tracking and trending reports.
- Oversees PDR staff to ensure that all Provider Disputes are acknowledged and resolved within standards set forth in AB1455 to ensure compliance; tracks and trends issues through reporting to identify root causes of disputes and works with appropriate areas (both internally and externally) to resolve issues.
- Serves as a back-up to processing of recoveries and disputes as needed to ensure that department and regulatory turnaround times are met.
- Ensures that regulatory audits are completed in a timely and efficient manner, providing support to Manager for preparation and review of audits.
- Plans work of staff and determine priorities of work done by staff. Responsible for prompt communication with staff including weekly unit meetings to review any changes to programs or training issues; conducts one-on-one meetings with staff to review their progress regarding their success factors (production, quality, etc.).
- Sets or recommends work performance standards. Reviews work procedures and recommends or changes procedures to be more time/cost efficient.
- Assists with interviewing job applicants and makes recommendation for hire.
- Completes and delivers annual employee performance reviews. Conducts employee counseling/corrective interviews with the assistance of Human Resources if needed.
- Performs other duties or special projects as assigned.
Required Skills
- Interact with others using a positive approach while dealing with sensitive matters concerning employees and/or Provider representatives.
- Encourage and utilize suggestions and new ideas, while troubleshooting problem areas.
- Establish and maintain successful interpersonal relationships with all levels of staff, other programs, agencies, and the general public.
- Communicate clearly and concisely, both verbally and in writing, with employees at all levels, while exhibiting fundamental principles of writing and grammar, including proper report and correspondence format.
- Interpret and utilize department reports for tracking and trending to provide education both internally and externally.
- Encourage the professional performance and development of all lower level staff.
- Plan, organize and prioritize work by managing and keeping track of multiple tasks.
- Effectively utilize computer and appropriate software (i.e. Microsoft Office Suite) to produce correspondence, charts, spreadsheets, and/or information applicable to the position assignment.
Required Experience
EXPERIENCE & EDUCATION:
- High school diploma or equivalent is required, some college is preferred.
- 5 years of experience in a managed care environment that would have developed the knowledge and abilities listed (i.e. Technical area(s) of medical claims administration, including medical terminology, CPT, ICD-9 codes and HCPCS codes, relevant business practices and applicable regulations/policies) is required.
- 3 years of experience in directing the work of others (i.e. training, responding to questions, etc.) is required.
KNOWLEDGE OF:
- Principles and techniques of effective supervision.
- Medi-Cal program guidelines.
- Medicare program guidelines.
- Benefits interpretation and administration.
Grade: K