- Oversee and manage daily activities and functions of the Claims Examiners processing claims for services that are capitated with the health plan.
- Responsible for overseeing the claim department's daily operations, including but not limited to, running daily/frequent reports to ensure claims are processed timely, accurately, and in compliance with all federal and state healthcare plan laws and regulations.
- Develop, implement, and update Claims Policies and Procedures to ensure compliance with CMS, Medicaid, HIPPA regulations, and health plan requirements.
- Report overpayments, underpayments, and other irregularities.
- Manage and close out claims open tickets and provider claims disputes.
- Ensure optimal handling of all claims, investigate claims issues, and provide claims training for all business units.
- Work together with Provider Servicing and participate in provider education, as necessary.
- Maintain a fully comprehensive understanding of the covered benefits, coding, and reimbursement policies and contracts.
- Act as Subject Matter Expert in issues related to claims processing, payment dispute resolution, cost containment, audit processes, and contract interpretation.
- Actively collaborate with management and staff to ensure that "best practices" are followed and continually seek efficient and innovative processes, technologies, and approaches to optimize the use of resources and enhance operations.
- Conduct analysis around various claims payment processes to ensure accuracy of system configuration and provider payments.
- Investigate and resolve problem claims, while focusing on improving errors and problems to prevent future occurrences.
- Perform and execute various claims process testing requests to ensure desired results are met to support accurate claims payments.
- Analyze and adjudicate complex claims when examiner is requesting Supervisor review.
- Adjudicate claims by, including but not limited to, applying medical necessity guidelines, determining coverage and completing eligibility verification, identifying discrepancies and applying all cost containment measures when necessary.
- Process medical claims by approving or denying documentation, calculating benefits due initiating a payment or denial letter when necessary.
- Follow any center for Medicare and Medicaid (CMS) changes affecting claims processing.
- Perform pre-payment audit and payment cycle.
- Complies with performance standards as set forth by the department head.
- Follow company policies, procedures, and guidelines to ensure legal compliance.
- Update claims knowledge by participating in educational opportunities, whether system oriented or medical coding/terminology/interpretation.
- Update and maintain departmental and specialty network standards of operating procedure (SOP).
- Regularly meet with VP of Operations - to discuss and resolve reimbursement issues or billing obstacles.
- Performs one on one meeting with the individual staff members.
- Bachelor's Degree or equivalent experience
- 3-5 years of Claims Management experience in the healthcare organization preferred
- 3-5 years of experience where you were responsible for setting standards and goals that met or exceeded company and client Service Level Agreements (SLA's).
- Intermediate Excel knowledge required.
- Demonstrated experience developing and lading process improvement projects that drove operations efficiencies.
- An entrepreneurial mindset geared toward creating, executing, and continuously improving health plan operations and implementations.
-
The Claims · Supervisor plays an essential role in supporting the claims manager and handling claims data efficiently. · ...
Coral Gables Full time1 month ago
-
We're a team of fast-paced fixers, empathetic experts, and outcomes drivers — people who care deeply about doing the right thing and doing it well. Whether you're managing claims, supporting clients or improving processes you'll play a vital role in helping businesses and individ ...
Miami, FL1 month ago
-
The Claims Supervisor manages the operational activities and staff of the Claims Department in accordance with the Company guidelines client needs and State and Federal requirements. · ...
Miami, FL1 month ago
-
:Position Summary · The Claims Supervisor manage the operational activities and staff of the Revenue Cycle Department in accordance with the Company guidelines, client needs, State and Federal requirements. · Duties and Responsibilities · Oversee and manages daily activities and ...
Miami, FL2 days ago
-
We're there when it matters most because helping people through challenging moments is more than just our job, it's our purpose. Every day, we help clients navigate complexity, support recovery, and deliver outcomes that make a real difference in people's lives. · + Supervise: Le ...
Miami Full time1 month ago
-
The Auto Claims Supervisor oversees property damage auto claims adjusters, ensures accurate claim evaluations, and drives operational excellence in claim handling. · Supervise and mentor a team of property damage adjusters, providing feedback, performance reviews, and training. · ...
Miami Gardens Full time1 month ago
-
The Auto Claims Supervisor oversees property damage auto claims adjusters and ensures accurate claim evaluations. · Supervise and mentor a team of property damage adjusters. · Review complex and escalated auto property damage claims for accuracy. · ...
Miami Gardens Full time1 month ago
-
We are seeking a Workers Compensation Claims Supervisor to lead and encourage a team handling a variety of caseload sizes and complexities. The ideal candidate will have prior leadership experience including supervisory experience and be licensed in all states where claims are be ...
Miami1 month ago
-
We help clients navigate complexity, support recovery and deliver outcomes that make a real difference in people's lives. Here you'll be supported by a culture that values teamwork and encourages curiosity. · Supervise Workers Compensation claims team handling various caseload si ...
Miami, FL1 month ago
-
Introduction · At Gallagher Bassett, we're there when it matters most because helping people through challenging moments is more than just our job, it's our purpose. Every day, we help clients navigate complexity, support recovery, and deliver outcomes that make a real difference ...
Miami $60,000 - $95,000 (USD) per year6 days ago
-
Description · Key Responsibilities · The PIP Supervisor is responsible for leading and guiding a team of Personal Injury Protection claims adjusters to ensure accurate, timely, and customer-focused handling of PIP claims. This role requires strong skills, deep technical knowledge ...
NW th Avenue Miami, Florida, United States1 week ago
-
Borinquen Medical Centers is based in Miami, Florida and is seeking to hire a full-time Front Desk Clerk to join our team. Under general supervision, the front desk clerk will be responsible to register and verify insurance of patients attending the clinic and ensuring that all p ...
Miami Springs $28,000 - $42,000 (USD) per year1 day ago
-
Requisition No: 870723 · Agency: Business and Professional Regulations · Working Title: REGULATORY SPECIALIST III · Pay Plan: Career Service · Position Number: · Salary: Hiring Salary: $1,396.82 to $1,531.54 Biweekly · Posting Closing Date: 03/08/2026 · Total Compensation Estim ...
Miami Springs $80,000 - $130,000 (USD) per year1 day ago
-
As an employee-owned distributor of natural and organic, specialty, and fresh products, we're committed to making a positive impact and scaling our success together. · ...
Hialeah $79,300 - $116,270 (USD)1 month ago
-
The Customer Service Representative (CSR), your primary responsibility is to respond to customer inquiries, process orders, and handle complaints promptly, courteously, and effectively. You will be one of our customers' first points of contact, providing exceptional support and a ...
Miami, FL $65,000 - $125,000 (USD) per year3 days ago
-
+The Division of Vocational Rehabilitation is seeking a Vocational Rehabilitation Technician to assist in providing services to eligible individuals with disabilities. The technician will perform administrative support and/or technical assistance to a VR unit and its customers. · ...
Miami, FL1 month ago
-
Manages the overall operation of the shopping center including accounting and asset management responsibilities, preparation of budgets and business plans; prospecting for local, regional, permanent, and temporary merchants; coordination of the local leasing program; establish an ...
Hialeah $125,000 - $165,000 (USD)2 weeks ago
-
Manages the overall operation of the shopping center including accounting and asset management responsibilities, preparation of budgets and business plans; prospecting for local, regional, permanent, and temporary merchants; coordination of the local leasing program; establish an ...
Hialeah $125,000 - $165,000 (USD) Full time2 weeks ago
-
We are pioneering a bold new approach to total health care. As health care innovators, we are making quality care affordable, accessible, simple and seamless. · ...
Hialeah $30 - $42 (USD) Full time2 months ago
-
The employee is responsible for monitoring program requirements under the National School Lunch Program and conducting on-site reviews in accordance with federal regulations. · ...
Doral, FL1 month ago
-
This position is located within the Bureau of Public Engagement of the Division of Condominiums, Timeshares and Mobile Homes. · Creating PowerPoint presentations that include educational material regarding the Division's program areas; · Speaking with constituents in person and t ...
Miami $1,902.64 - $2,077.78 (USD) Full time1 month ago
Healthcare Claims Supervisor - Miami Springs - Provider Network Solutions
Description
Job TypeFull-time
Description
Position Summary
The Claims Supervisor manages the operational activities and staff of the Claims Department in accordance with the Company guidelines, client needs, and State and Federal requirements.
Duties and ResponsibilitiesKnowledge
$60, $65,000.00 per year
-
Claims Supervisor
Full time Only for registered members Coral Gables
-
Claims Supervisor
Only for registered members Miami, FL
-
Healthcare Claims Supervisor
Only for registered members Miami, FL
-
Claims Fee for Service Supervisor
Only for registered members Miami, FL
-
Workers Compensation Claims Supervisor
Full time Only for registered members Miami
-
Auto Claims Supervisor
Full time Only for registered members Miami Gardens
-
Auto Claims Supervisor
Full time Only for registered members Miami Gardens
-
Workers Compensation Claims Supervisor
Only for registered members Miami
-
Workers Compensation Claims Supervisor
Only for registered members Miami, FL
-
Workers Compensation Claims Supervisor
Gallagher Bassett- Miami
-
PIP Claims Supervisor- Miami, FL
Only for registered members NW th Avenue Miami, Florida, United States
-
front desk
Only for registered members Miami Springs
-
regulatory specialist iii
Only for registered members Miami Springs
-
Human Resource Manager
Only for registered members Hialeah
-
Customer Service Representative
Only for registered members Miami, FL
-
vocational rehabilitation technician
Only for registered members Miami, FL
-
General Manager
Only for registered members Hialeah
-
General Manager
Full time Only for registered members Hialeah
-
Foreign Pharmacy Grad
Full time Only for registered members Hialeah
-
fnw program specialist iv
Only for registered members Doral, FL
-
research & training specialist - 79001453
Full time Only for registered members Miami