Claims Supervisor in Modesto, California at SAN JOAQUIN COUNTY HEALTH COMMISSION

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

This is a remote position. Must reside in California, preferably in our service area.

What You Will Be Doing:

Under general supervision, the Claims Supervisor is responsible for providing oversight and coordinating the daily operations of claims production or claims adjustment and auditing functions in a manner that meets established turnaround, quality and production goals, and regulatory standards. Work is varied and minimally to moderately complex and requires a limited to moderate degree of discretion and independent judgment.

Supervises

• Claims Analysts

Essential Functions

• Plans and assigns work; monitors department workload to ensure mandated turnaround times are met; makes timely and effective adjustments.
• Identifies, monitors and analyzes appropriate metrics, including production, inventory and submission/billing patterns; develops timely and effective corrective action plans based on findings.
• Develops, implements and maintains department policies and procedures; makes recommendations for revisions; communicates changes to appropriate individuals in a timely and effective manner.
• Responds to and resolves or facilitates resolution of complex claims, appeals, provider disputes, and third-party liability cases.
• Assists with the development and implementation of department-related upgrades and enhancements of transaction system and other tools.
• Identifies, monitors and analyzes transaction system processing issues; corrects or escalates as required.
• Works closely with interdepartmental units to improve workflow and processes: identifies issues and opportunities; initiates meetings; resolves issues or makes recommendations as required.
• Prepares for and participates in regulatory audits: compiles audit packets, provides information, develops and monitors timely and effective corrective action plans.
• Executes and monitors business plans; assists in the development and monitoring of department budget.
• Identifies training needs and opportunities; develops and delivers routine and ad hoc department training.
• Promotes and maintains an environment that supports HPSJ’s strategy, vision, mission and values.
• Hires, supervises and retains a competent staff.

What You Bring:

Knowledge, Skills, Abilities and Competencies

Required

• In-depth knowledge of: procedure coding and medical terminology, and their application in benefits; general medical policy benefits and exclusions; industry standard payment practices.
• In-depth knowledge of claims processing systems, including coding.
• Basic knowledge of claims administration metrics models.
• Basic knowledge of audit processes, and the ability to effectively implement and maintain them.
• Ability to read, interpret and apply complex written guidelines, instructions and other materials.
• Ability to develop, execute and monitor relevant business plans.
• Basic analytical skills.
• Decision quality: Makes good and timely decisions that keep the organization moving forward.
• Action oriented: Takes on new opportunities and tough challenges with a sense of urgency, high energy and enthusiasm.
• Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.
• Directs work: Provides direction, delegates and removes obstacles to get work done.
• Plans and aligns: Plans and prioritizes work to meet commitments aligned with organization goals.
• Optimizes work processes: Knows the most effective and efficient process to get things done, with a focus on continuous improvement; can develop, implement and maintain processes.
• Ensures accountability: Holds self and others accountable to meet commitments.
• Drives results: Consistently achieves results, even under tough circumstances.
• Organizational savvy: Maneuvers comfortably through complex policy, process and people-related organizational dynamics.
• Being resilient: Rebounds from setbacks and adversity when facing difficult situations.
• Courage: Steps up to address difficult issues, says what needs to be said.
• Situational adaptability: Adapts approach and demeanor in real time to match the shifting demands of different situations.
• Strong oral and written communication skills with the ability to communicate with diverse individuals inside and outside of HPSJ.
• Good presentation skills.
• Strong facilitation, problem solving and conflict resolution skills.
• Strong interpersonal skills with the ability to maintain effective working relationships with diverse individuals inside and outside of HPSJ
• Ability to commit to and facilitate an atmosphere of collaboration and teamwork.
• Strong customer service skills.
• Demonstrated ability to articulate and support HPSJ’s vision, mission, values and strategy, integrate into management practices, and foster their manifestation among staff.
• Demonstrated ability to supervise staff in a manner that maximizes employee performance and business results.
• Ability to develop and deliver relevant and effective training and supporting materials.
• Intermediate skills in Word and Excel, including the ability to develop formulas and links.
• Basic mathematics skills.
• Ability to speak and be understood in English.
• Ability to handle confidential information with appropriate discretion.

Preferred

• In-depth knowledge of regulations and procedures governing Medi-Cal and other state sponsored programs.
• In-depth knowledge of the principles and practices of managed care.

What You Have:

Education and Experience

Required

• HS diploma.
• At least one year experience as a claim's supervisor in healthcare; or
• At least two years’ experience as a claims lead in healthcare; or
• At least four years progressively responsible experience in healthcare claims.

Preferred

• Associate’s degree.
• Managed care experience.

Licenses, Certifications

Required

• None

What You Will Get:

HPSJ Perks:

Physical Demands

Work may require frequent sitting, standing, and walking, constant repetitive motion, frequent talking and listening, closeup and distance vision requirements. Some work may require occasional travel based on the responsibilities of the position and business needs and occasional handling materials up to 50 pounds.

Emotional/Psychological Demands

Ability to cope with a fast-paced work environment, working under pressure, dynamic priorities and deadlines, constant decision making, working irregular hours, emotional and sensitive situations.

Work Environment

Work may be performed in a remote, hybrid, or onsite setting depending on the requirements of the position and business needs. For roles performed remotely, employees are expected to maintain a secure, distraction-free workspace, and reliable internet connectivity consistent with company standards.

Important Notice: The duties, qualifications, and physical and emotional requirements listed in this job description are not exhaustive. Health Plan of San Joaquin reserves the right to revise this job description at any time.