Supervisor, Claims

Work set-up: 
Full Remote
Contract: 
Experience: 
Senior (5-10 years)
Work from: 

Offer summary

Qualifications:

Bachelor's degree required., 3 to 5 years of supervisory experience in medical/dental claims., Expertise in medical and dental claim processing and healthcare coding., Knowledge of electronic claim transactions (EDI) and healthcare regulations like HIPAA, ACA, COBRA..

Key responsibilities:

  • Lead and develop a team of claims professionals.
  • Ensure claims processing meets quality, accuracy, and compliance standards.
  • Manage electronic data interchange (EDI) activities and improve workflows.
  • Support department operations through research, training, and process improvements.

Western Growers Family of Companies logo
Western Growers Family of Companies Non-profit Organization - Charity SME https://www.wga.com/
201 - 500 Employees
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Job description

Description

Western Growers Health─a part of Western Growers Family of Companies─provides employer-sponsored health benefit plans to meet the needs of those working for the agriculture industry. The unmatched benefit options provided by Western Growers Health stem from the core mission of Western Growers Association (est. 1926) to support the business interests of employers in the agriculture industry.

Our mission at Western Growers Health is to deliver value to employers by offering robust health plans that meet the needs of a diverse workforce. By working at Western Growers Health, you will join a dedicated team of employees who care about offering quality health benefits and excellent customer service to plan participants. If you want to start making a difference working in the health care industry, then apply to Western Growers Health today!

Compensation: $61,719.12 - $85,234.24 with a rich benefits package that includes profit-sharing. This is a remote position and can reside anywhere in the U.S.
    
JOB DESCRIPTION SUMMARY
Position reports to the Manager of Claims. The Supervisor of Claims coaches, counsels, and trains staff per company policies. The Supervisor is responsible for monitoring and distributing daily inventory, promoting quality and superior customer service, and identifying enhancements to service and production. Additionally, they monitor the Electronic Data Interchange (EDI) activity accuracy and change workflows to increase effectiveness and productivity. This position will oversee Team Leads, Examiners, and Clerks.
Qualifications
  • BS/BA degree and a minimum of three (3) to five (5) years of recent experience as a supervisor of a medical/dental claims operation preferred.
  • Subject matter expertise in medical and dental claim processing, principles, and procedures.
  • Strong understanding of electronic claim transactions (EDI) and healthcare code sets (CPT, HCPCS, ICD10 & revenue codes) across commercial plans, including MEWA, ERISA-based, and self-funded plans.
  • Ability to interpret provider contracted rates, including letters of agreement, and apply them to the claim adjudication.
  • Strong understanding of regulatory requirements, including ACA, HIPAA, and COBRA.
  • Excellent written and verbal communication, multi-tasking, research, and problem-solving skills.
  • Demonstrated ability to work collaboratively in a team environment, facilitate meetings, conduct training sessions, and support team decisions.
  • Ability to research and create clear and concise procedures for handling complex claims. 
  • Proficient knowledge of word processing, data evaluation, and spreadsheet end-user office software.
  • Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
  • Home router with wired Ethernet (wireless connections and hotspots are not permitted).
  • A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
  • A functioning smoke detector, fire extinguisher, and first aid kit on site.

 
Duties And Responsibilities
Management & Leadership
  • Develop, manage, and lead a team of 3A+ self-accountable professionals.
  • Develop a culture of authentic, personal accountability by modeling the behavior that defines it.
  • Instill a culture of safety and expectation within your respective area/s.
  • Require direct reports to hold themselves accountable to high performance standards and personal conduct in a clear, helpful, straightforward way.
  • Conduct one-on-one conversations with every direct report quarterly focused on their 3A+ capabilities, impact, and effort.
  • Make decisions impacting staff using the steps outlined in the “Outward Leadership” guide.
Department Operations
  • Ensure that claims processing meet department production and accuracy standards and that all claim department activities remain compliant with laws, regulations, policies, and contractual client requirement, including turn-around time and quality results. 
  • Perform research and provide technical support on claim processing issues and adjudication discrepancies to department staff.
  • Assist other departments and Claims leadership in researching and resolving inquiries, appeals, and claim payment discrepancies. 
  • Manage the EDI interchange process and ensure that no more than 3% of electronic submissions reject to paper or letter for each day’s receipts across clearinghouses, networks, and vendors. 
  • Manages daily inventory (electronic or paper), daily Examiner pend inventory, and distribution of work to department staff to minimize claims turn-around times.  
  • Track and report monthly production and quality measurements to claims staff and leadership, and monitor and review daily audit results with team members. 
  • Prepare daily and weekly reports for the Manager, Claims.
Process Improvements & Cost Containment
  • Continuously review and improve business processes designed to improve accuracy, timeliness and reduce claim costs or manual effort. 
  • Track and trend qualitative and quantitative data on department processes, analyze results, perform root cause analysis, and identify and execute improvement actions.  
  • Identify staff training needs, support training development, and coordinate ongoing or ad-hoc training. 
  • Train, coach, and develop staff in department policies and procedures to maintain department and organizational standards and meet strategic objectives.
  • Develop, maintain and update standard operating procedures, work instructions, and workflows that capture the processes for department functions.
  • Collaborate across functional departments to align, streamline and improve cross-department processes and communication.

 
Other
  • Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, be self-accountable, create a positive impact, and be diligent in delivering results.
  • Maintain internet speed of at least 40 MB download and 10 MB upload and router with wired Ethernet.
  • Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
  • Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
  • All other duties as assigned.
 
Physical Demands/Work Environment
The physical demands and work environment described here represent those that an employee must meet to successfully perform this job’s essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.
#LI-Remote

Required profile

Experience

Level of experience: Senior (5-10 years)
Industry :
Non-profit Organization - Charity
Spoken language(s):
English
Check out the description to know which languages are mandatory.

Other Skills

  • Team Leadership
  • Microsoft Excel
  • Research
  • Microsoft Word
  • Problem Solving
  • Multitasking
  • Training And Development
  • Collaboration
  • Communication

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