Job Description

OUR CLIENT, A WELL-RESPECTED CALIFORNIA BASED HEALTHCARE NETWORK, IS A SEEKING A CLAIMS SUPERVISOR TO JOIN ITS OPERATIONAL SUPPORT TEAM.

The Claims Supervisor, Operational Support, manages the day-to-day operations of the operational support staff, which includes the Analytics team. The incumbent is responsible for following regulatory and internal guidelines in conjunction with policies and procedures as they apply to claims operational support for Medi-Cal and Medicare, OneCare and Programs of All-Inclusive Care for the Elderly (PACE).

POSITION RESPONSIBILITIES

• Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short and long-term goals/priorities for the department.
• Trains and supervises all operational support employees to ensure adherence to the Medi-Cal and Medicare regulatory and processing guidelines.
• Identifies learning opportunities for staff (e.g., new desktops, recovery, and provider education).
• Maintains presence at workshops related to claims guidelines 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.
• Assigns Projects and determines priorities of work done by staff.
• Responsible for prompt communication with staff including bi-weekly team meetings to review any updates or claims issues; conducts one-on-one meetings with staff to review their progress regarding their success factors (e.g., production, quality, etc.).
• Sets or recommends work performance standards.
• Reviews work procedures, recommends changes and/or changes procedures to be more time and cost efficient.
• Assists with interviewing job applicants and makes recommendations for hire.
• Completes and delivers annual employee performance reviews.
• Conducts employee counseling and corrective interviews with the assistance of Human Resources, if needed.
• Completes other duties or special projects as assigned.

POSSESSES THE ABILITY TO:

• 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 effective working relationships with leadership and 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.
• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment.

EXPERIENCE & EDUCATION

• High school diploma or equivalent required.
• 3 years of experience in a managed care environment in technical areas of medical claims administration required.
• 2 years of progressive leadership experience, including the direct supervision of staff, in operational aspects of key functional areas in claims support required.

PREFERRED QUALIFICATIONS

• Bachelor’s degree in Business Administration, Health Care Administration, or related field preferred.

KNOWLEDGE OF:

• Medical terminology, Current Procedural Terminology (CPT), International Classification of Diseases (ICD)-10 codes and Healthcare Common Procedure Coding System (HCPCS) codes.
• Principles and techniques of effective supervision.
• Medi-Cal and Medicare program guidelines, regulations, and policies.
• Benefits interpretation and administration.

Company Description

This company has plenty of room to grow and truly values their employees!