Claims Specialist Supervisor / Job Req 688155089

PRINCIPAL RESPONSIBILITIES:

Under general direction from the Manager, Claims Operations Support, the Supervisor, Claims Specialist is responsible for the day-to-day supervision of Claims Specialist roles, collaborating with other department Supervisors and other department leadership members, in order to meet and exceed performance targets. Specialist staff activities include, but are not limited to, research and resolution, auditing, refund processing and claims system analysis/testing.

The Claims Specialist Supervisor is responsible for ensuring that processed claims are reviewed and audited to help assess work performance, assist in identifying training needs and opportunities for workflow and system configuration improvements. The Supervisor also oversees staff responsible to provide testing of system functionality on new and existing products, and to receive and respond to requests for assistance on Service Requests and Provider inquires in a timely and accurate manner by communicating and enforcing department goals and objectives within a total quality management approach and in compliance with all applicable state/federal regulations. The Supervisor will assist the department's leadership team in monitoring and enforcing production and quality standards, ensuring compliance with all operating policies and procedures and claims processing guidelines, and collaborating with other departments to ensure the Alliance's business, operating and reporting goals are met.

Other principal responsibilities include:

• Provide day-to-day supervision of Claim Specialists staff.
• Work with Manager, Claims Operations Support to develop, and implement unit production goals, then assign and monitor daily workload to ensure goals are achieved.
• Oversee the preparation of routine and ad hoc reports.
• Respond to escalated provider claim inquiries received by Provider Services, Grievance and Appeals and other Departments as needed.
• Provide advice to other Alliance departments on claims related issues by phone, email or in person.
• Prepare, review, and approve staff timecards, approve/deny requested time off, and monitor attendance.
• Hire, coach and develop staff to accomplish organizational objectives.
• Monitor and provide feedback on staff performance, recognizing strengths and coaching towards improved performance where necessary.
• Implement corrective action plans and discipline as necessary.
• Conduct scheduled performance appraisals in a timely and thoughtful manner.
• In conjunction with the Claims Production Manager, Claims Trainer and Claims Processing Supervisors, assemble and maintain training guidelines and tools.
• Conduct monthly one-on-one meetings with staff.
• Conduct weekly team meetings.
• Review Inventory, Quality and Production reports weekly.
• Review and improve Service Request workflow. Suggest improvements to current departmental workflows and systems.
• Monitor Service Requests and adjustment projects to ensure timely completion.
• Oversee all system testing activities related to new software implementation, system upgrades or routine system configuration changes.
• Ensure that the Department adheres to all state and federal regulations, contract requirements, and service level agreements.
• Assist in the preparation for all internal, external and regulatory audits.
• Represent the Alliance, as needed, during internal or external audits of Alliance claims processing.
• Perform other duties and special projects as assigned.

PHYSICAL REQUIREMENTS

• Constant and close visual work at a desk or a computer.
• Constant sitting and working at a desk.
• Constant data entry using a keyboard and/or a mouse.
• Constant use of a telephone headset.
• Constant verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders and various other objects weighing between 0 and 20 pounds.
• Frequent walking and standing.

Number of Employees Supervised: 10-15

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

• Bachelor's degree required or a combination of education and equivalent work experience.
• High School Diploma or GED required.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Minimum of five years in a managed care claims processing environment processing all claim types (e.g., inpatient, outpatient, professional, SNF, DME, Home Health, COB) required.
• Three plus years' experience with Medi-Cal guidelines and claims processing applications required, including experience with all types of claims (professional, ancillary, facility)
• Three plus years' experience handling complicated claims issues required (manual pricing, late interest payment calculations, COB, adjusting previously processed claims, etc.).
• Two years' experience reviewing and responding to grievances and/or disputes from providers and/or members required.
• Two years' experience in a Supervisor, Trainer, Quality Assurance or Auditor role highly preferred.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Must have detailed knowledge of CPT, HCPCS, RVS, ICD-10, CMS1500/UB04 coding and forms.
• Experience with HIPAA and EDI transaction processing required.
• Previous experience as a Trainer or an Auditor in a claims environment desired.
• Excellent leadership, organizational, verbal and written communication skills, and problem-solving skills.
• Excellent customer service skills.
• A "hands-on" leader.
• Experience with claims auditing.
• Ability to develop, monitor and adjust production standards.
• Well organized and detail oriented.
• Ability to handle multiple projects and balance competing priorities.
• Previous experience in a high-volume electronic claims processing system.
• Experience in use of various computer system software, including Microsoft Office products.
• Prior claims processing experience in RAM HealthSuite a plus.

ESSENTIAL FUNCTIONS OF THE JOB

• Hire, train, lead and evaluate staff; build an effective team and assist in ensuring appropriate staffing and staff development.
• Identify problems, perform appropriate analysis and determine options for resolution.
• Collect needed data, information and/or analyses to assist in resolving complex claims issues and/or large volume claim adjustment projects.
• Produce reports on daily, weekly, and on an ad hoc basis.
• Communicate effectively and efficiently, internally and externally, in written and verbal formats.
• In collaboration with the Claims Trainer and Claims Processing Supervisors, develop and maintain documented claims procedures as a routine function.
• Ensure system configuration changes are producing the expected results.
• Respond to inquiries from other Alliance departments on claims related issues via phone, email or in person.
• Lead and/or participate in internal committees and meetings.
• Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

SALARY RANGE $92,051.06-$138,076.59 ANNUALLY

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.