Supervisor, Claims

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

• 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.

• 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.

• 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.

• 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