Healthcare Claims Supervisor

Position Summary

The Claims Supervisor manages the operational activities and staff of the Claims Department in accordance with the Company guidelines, client needs, and State and Federal requirements.

Duties and Responsibilities

• Oversee and manage daily activities and functions of the Claims Examiners processing claims for services that are capitated with the health plan.
• Responsible for overseeing the claim department’s daily operations, including but not limited to, running daily/frequent reports to ensure claims are processed timely, accurately, and in compliance with all federal and state healthcare plan laws and regulations.
• Develop, implement, and update Claims Policies and Procedures to ensure compliance with CMS, Medicaid, HIPPA regulations, and health plan requirements.
• Report overpayments, underpayments, and other irregularities.
• Manage and close out claims open tickets and provider claims disputes.
• Ensure optimal handling of all claims, investigate claims issues, and provide claims training for all business units.
• Work together with Provider Servicing and participate in provider education, as necessary.
• Maintain a fully comprehensive understanding of the covered benefits, coding, and reimbursement policies and contracts.
• Act as Subject Matter Expert in issues related to claims processing, payment dispute resolution, cost containment, audit processes, and contract interpretation.
• Actively collaborate with management and staff to ensure that “best practices” are followed and continually seek efficient and innovative processes, technologies, and approaches to optimize the use of resources and enhance operations.
• Conduct analysis around various claims payment processes to ensure accuracy of system configuration and provider payments.
• Investigate and resolve problem claims, while focusing on improving errors and problems to prevent future occurrences.
• Perform and execute various claims process testing requests to ensure desired results are met to support accurate claims payments.
• Analyze and adjudicate complex claims when examiner is requesting Supervisor review.
• Adjudicate claims by, including but not limited to, applying medical necessity guidelines, determining coverage and completing eligibility verification, identifying discrepancies and applying all cost containment measures when necessary.
• Process medical claims by approving or denying documentation, calculating benefits due initiating a payment or denial letter when necessary.
• Follow any center for Medicare and Medicaid (CMS) changes affecting claims processing.
• Perform pre-payment audit and payment cycle.
• Complies with performance standards as set forth by the department head.
• Follow company policies, procedures, and guidelines to ensure legal compliance.
• Update claims knowledge by participating in educational opportunities, whether system oriented or medical coding/terminology/interpretation.
• Update and maintain departmental and specialty network standards of operating procedure (SOP).
• Regularly meet with VP of Operations - to discuss and resolve reimbursement issues or billing obstacles.
• Performs one on one meeting with the individual staff members.

Knowledge

• Bachelor’s Degree or equivalent experience
• 3-5 years of Claims Management experience in the healthcare organization preferred
• 3-5 years of experience where you were responsible for setting standards and goals that met or exceeded company and client Service Level Agreements (SLA’s).

Skills

• Intermediate Excel knowledge required.
• Demonstrated experience developing and lading process improvement projects that drove operations efficiencies.
• An entrepreneurial mindset geared toward creating, executing, and continuously improving health plan operations and implementations.