Healthcare Claims and Fee for Service Supervisor in Miami, Florida at Provider Network Solutions LLC

Position Summary

The Claims and Fee for Service Supervisor manages the operational activities and staff of the Claims and Revenue Cycle Department in accordance with the Company guidelines, client needs, and State and Federal requirements.

Duties and Responsibilities

• Oversee and manage daily activities and functions of the Claims Examiners processing claims for services that are capitated and Fee for Service with the health plan.

• Responsible for overseeing the Revenue Cycle Management and Claims 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. As well as, posting of all 835 payments.

• 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.

• Perform one-on-one meeting with the individual staff members.

Knowledge

• Bachelor’s degree in health administration, Business, or a related field (or equivalent experience).

• 5+ years of experience in healthcare claims processing, Revenue Cycle Management, or medical billing; 2+ years in a supervisory or lead role preferred.

• Strong understanding of CMS, Medicare, Medicaid, HIPAA, and healthcare compliance standards.

• Proficiency with medical coding systems (ICD-10, CPT/HCPCS) and claims adjudication platforms.

• Experience with payment posting, audits, dispute resolution, and claims system testing/UAT.

• Experience using AI applications to streamline claims processing, improve accuracy in claim evaluations, and enhance decision-making efficiency.

Skills

• Analytical & problem-solving skills to resolve complex claims, identify root causes, and ensure accurate payments.

• Leadership & supervisory skills for managing daily operations, coaching staff, and conducting performance meetings.

• Strong communication abilities to collaborate with providers, internal teams, and senior leadership.

• Process & policy development skills, including writing SOPs, implementing best practices, and ensuring regulatory compliance.

• Technical proficiency in claims platforms, RCM systems, Excel/reporting, and conducting system/UAT testing.