Requisition #: M12075
Working Title: Claims Supervisor
Business Entity: MDN - Medical Delivery Network
Cost Center # - Cost Center Name: 0853015 - MNS - Managed Care
Job Category: Management/Professional
Job Specialty: Supervisor/Team Lead
Position Type: Regular-F/T
Shift Length: 8hr
Days: Monday - Friday
Shift Type: Day
Job Posting: The Claims Supervisor directly supervises claims examiners and carries out supervisory responsibilities in accordance with the organization’s policies and applicable laws. The Claims Supervisor is responsible for a higher-level expertise in the analysis and management of professional, outpatient and inpatient facility claims.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Responsible for supervising the overall quality of claims processes as they pertain to departmental policies and procedures as well as compliance, in accordance with CMS, DMHC, and Health Plan and contractual obligations.
2. Responsible for coordinating subordinate employee recruitment, performance assessment, work assignments, salary, and recognition/disciplinary actions.
3. Provide training support for new employees and existing claims examiners on policies and procedures and regulatory guidelines in accordance with CMS, DMHC, Health plan and contractual agreements.
4. Distributes work through review of inventory and pended claim reports.
5. Provide expertise and/or general claims support to teams in reviewing, resolving, member and provider appeals and disputes.
6. Responsible to process and respond to Health Plan inquiries and coordinates with appropriate departments for any provider, member, or system issues.
7. Responsible for recommending changes in guidelines, procedures, and policies. Ensuring the use of best practice workflows and operational excellence in activities are utilized.
8. Direct the training of team members on workflow and contractual modifications expeditiously.
Education Certifications/Licensure Experience Physical Abilities EXPERIENCE
Minimum of 2+ years supervisory experience or an equivalent combination of education and experience. 5+ years of any of the following combined: claims auditing, professional and facility claims processing for Medicare and Commercial products, provider dispute resolution processing in an IPA, HMO and Hospital related setting.
High School Diploma
Ability to interpret Health Plans Division of Financial Responsibility for both IPA and Hospital Risk as well as interpreting contracts. Experience with processing all types of specialty claims such as chemotherapy, dialysis, drug and multiple surgery claims. Knowledge of medical terminology, CPT, HCPCS, Revenue Codes and ICD-10 codes. Working knowledge of coordination of benefits and Correct Coding Initiative edits. Experience on an automated claims processing system (Epic Tapestry preferred). Experience with Microsoft Outlook, Word, Excel, Access. Must be organized and able to meet ongoing as well as special time deadlines and work under pressure.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Requires prolonged sitting, some bending, stooping and stretching. Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment. Requires normal range of hearing and eyesight to record, prepare and communicate appropriate reports.
Location/Region: Los Angeles, CA (US)