- Supervise day-to-day claims operations tasks in accordance with established policies and procedures, standard operating procedures, and job aids to ensure optimal performance results.
- Monitor and track claim inventory / workflow through the entire claim life cycle to ensure timely processing of claims based on regulatory and contractual compliance requirements.
- Oversight of all aspects of departmental monitoring tools and controls to promote operational excellence
- Responsible for driving team results based upon established departmental quality and production performance metrics.
- In collaboration with the Claims Quality Assurance and Training teams, review audit results to evaluate opportunities for staff development, training, and remediation needs to maximize claim outcomes.
- Develop strategies to improve upon departmental effectiveness and efficiencies. Identifies and implements process improvement opportunities that focus on customer value.
- Serve as a subject matter expert and liaison with internal and external customers to address claim issues in an expeditious, accurate method.
- Assist in formulating and executing initiatives to achieve departmental goals and objectives.
- Select and build strong, professional functional teams through training reinforcement, coaching, motivation, and performance management. Complete and track effective performance evaluations and maintain ongoing dialogue with team members regarding development opportunities.
- Assist Claims Management in identifying, creating, and implementing policies and procedures, standard operating procedures, and desk top references.
- Make recommendations to leadership on changes and additions to department procedures through innovative thinking with an emphasis on automation.
- Attend regulatory audits for assigned line-of-business and actively participate as a claims SME on processes and procedures for the claims department.
- Stay current with changes mandated by the regulatory agencies and industry standard processes.
- Attend key strategic meetings that are necessary to maintain a viable knowledge base within IEHP. Initiate and conduct internal meetings as well as adding substance to discussions, sharing new ideas, personal perspectives, and provides relevant follow-up items.
- Serve as a support to the Claim Operations Manager for absences, spike claim receipts, etc.
- Any other duties as required to ensure IEHP operations are successful.
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Supervisor, Claims Processing - Vallejo, United States - Inland Empire Health Plan
Description
What you can expectFind joy in serving others with IEHP We welcome you to join us in "healing and inspiring the human spirit" and to pivot from a "job" opportunity to an authentic experience
The Supervisor, Claims Processing – Medi-Cal provides daily oversight of claims staff, business processes and inventory management. Ensures the claims team follows state/federal regulations and standard operating procedures. Develops best practices to optimize claim processing quality. Evaluates professional skills of team members and provide appropriate work assignments. Resolve claim payment issues and quality oversight. Assist in hiring and training new team members in their job responsibilities. Monitors individual and team performance to ensure quality and performance objectives are met. Assist in employee performance evaluation, coaching and professional development activities to improve performance efficiency.
Major Functions (Duties and Responsibilities)
Commitment to Quality:
The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.
Perks
IEHP is not only committed to healing and inspiring the human spirit of our Members; we also aim to match our Team Members with the same energy by providing prime benefits and more.
457(b) option with a contribution match
Generous paid time off- vacation, holidays, sick
State of the art fitness center on-site
Medical Insurance with Dental and Vision
Paid life insurance for employees with additional options
Short-term, and long-term disability options
Pet care insurance
Flexible Spending Account – Health Care/Childcare
Wellness programs that promote a healthy work-life balance
Career advancement opportunities and professional development
Competitive salary with annual merit increase
Team bonus opportunities
Education & Experience
Four (4) years medical claims processing experience, at least two (2) years of experience in a supervisory capacity leading a team.
Experienced in benefit and financial matrix interpretation.
Experience preferably in an HMO or Managed Care setting.
High School diploma or GED required.
Bachelor's degree from an accredited institution preferred.
Key Qualifications
A thorough understanding of claims industry and customer service standards. Knowledge in CMS, DHMC and DHCS regulatory guidelines including AB1455. Extensive knowledge of ICD-9, ICD-10, CPT, and Revenue Codes.
Solid understanding of the DHCS, DMHC and CMS rules and regulations governing claims adjudication practices and procedures desired.
Principles and techniques of supervision and training.
Knowledge of medical terminology and understanding of healthcare claims.
Analytical skills with emphasis on time management, data base maintenance, spreadsheet manipulation, and problem solving.
Strong writing, organizational, project management, and communication skills proficiency required.
Excellent interpersonal/communication skills.
Must have a high degree of patience and ability to lead a large team of professionals.
Start your journey towards a thriving future with IEHP and apply TODAY
