Supervisor, Claims

Job Number: 3545

Workplace Type: Hybrid Remote

Position Title: Supervisor, Claims

External Description:

Position Summary:
The Supervisor, Claims is responsible for the daily supervision of Claims Examiners and Clerical employees. Assists the Manager, Claims for supervision of accurate and timely adjudication of claims according to contractual and regulatory guidelines.  The Supervisor, Claims is also responsible for ensuring policies, procedures, workflows are administered appropriately. 

The Supervisor will create and foster a positive and productive work environment and mentor staff to encourage and promote growth. This includes supervising individual and ensuring team performance expectations and goals are met. Works with Manager, Claims in providing individual coaching and feedback sessions and maintaining singular focus to improve performance.

 

 

General Duties/Responsibilities:

Essential duties and responsibilities include but are not limited to:

• Supervise Claims production staff which include but not limited to Claims Examiners and Clerical staff
• Play a key role in assisting Manager, Claims problem resolution, workflow optimization and process improvement
• Provide oversight to claims daily inventory to ensure compliance in all areas
• Monitor key performance metrics, communicates and recommends process improvements to Manager, Claims and/or other Senior Management
• Create and maintain reports supporting all functional area of claims productions
• Perform root cause analysis and identifies errors and trends for paid claims
• Review system set-up for claims payment accuracy
• Subject matter expert in claims in-load process for claims processing (i.e. fee schedules, benefit structure, provider adds, etc.)
• Assist in the oversight and monitoring of claims administrative vendor which include but not limited to scanning and claims forwarding/misdirects.
• Assist Claims Management in
• Assist in resolving claim payment settlements, legal reviews and investigations when necessary
• Handle special projects as assigned and required by changes in claims payment policies or contractual obligation

• Provide continual evaluation of processes, procedures, and training gaps
• Assist in training new staff and re-train tenured staff on new processes
• Monitor productivity and quality of employees
• Provide regularly scheduled one-on-one coaching with staff
• Handle escalated customers’ questions and concerns

• Updates systems, tracking tools or other documentation methods as needed
• Identifies data trends and reports findings to department management with suggestion for resolution and opportunities for process improvement
• Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance
• Ensure information flow of updates and changes to staff for developing and motivation

• Establish creative ways to increase team performance 
• Other related duties as assigned

Minimum Requirements:

• High School Diploma, G.E.D. or equivalent
• 3+ years of supervisory experience (or equivalent experience) with a Health Plan or Medical Group (Medicare preferred)
• 5+ years of any of the following combined: claims auditing, claims processing, claims dispute/appeals processing, claims customer service
• Computer Skills: Knowledge of applications, computer programs and applications required
• Knowledge of claims processing, adjusting and auditing
• Detail oriented
• Knowledge of computerized claims processing systems
• Knowledge of MS Office – Outlook, Word, and Excel
• Working knowledge of CPT, RVS, ICD-9/ICD-10, HCPCS or other coding
• Knowledge of State and Federal Regulatory claims requirements
• Excellent verbal and written skills
• Knowledge of claims processing systems (EZCAP preferred)
• Knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-9, ICD-10, DRG, etc.
• Experience in processing/adjudicating medical, hospital claims
• Experience in handling provider payment disputes and appeals is preferred
• Proven problem-solving skills and ability to translate knowledge to the department
• Ability to multitask
• Strong Organizational Skills
• Attention to Detail
• Familiarity with CMS regulatory requirements
• Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals.  Ability to write routine reports and correspondence.  Ability to speak effectively before groups of customers or employees of the organization.
• Mathematical Skills: Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.  Ability to apply concepts of basic algebra and geometry.
• Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.  Ability to deal with problems involving a few concrete variables in standardized situations.

Essential Physical Functions:

The physical demands described here are 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.

• While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
• The employee is frequently required to reach with hands and arms.
• The employee is occasionally required to stand; walk; climb or balance and stoop, kneel, crouch, or crawl.
• The employee must occasionally lift and/or move up to 25 pounds.
• Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

 

Working Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• The noise level in the work environment is usually moderate

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Supervisor, Claims

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].