Claims Resolution and Reconciliation Supervisor

The Claims Resolution and Reconciliation Supervisor oversees daily claims resolution operations, ensuring timely, accurate, and compliant processing of complex claims adjustments, provider disputes, appeals, and grievances. This role provides direct supervision to staff, supports operational performance, and ensures compliance with Department of Managed Health Care (DMHC) and Centers for Medicare & Medicaid Services (CMS) requirements, industry standards, and organizational standards.

Key Responsibilities

• Supervise Claims Adjustment Specialists and Provider Dispute Resolution Analysts, including workload distribution, training, coaching, and performance management.
• Oversee daily claims operations to ensure accurate and timely resolution of complex claims adjustments, disputes, and escalated issues.
• Monitor productivity, quality, and inventory metrics to support operational goals and identify trends or areas for improvement.
• Ensure compliance with CMS, DMHC, and internal claims processing policies and procedures.
• Review and approve complex or high-dollar claims within established authority levels.
• Develop and maintain operational reports, workflows, desk procedures, and supporting documentation.
• Support audits, system testing, and implementation activities related to claims operations.
• Collaborate with cross-functional teams to resolve systemic claims issues and improve operational efficiency.