Claims Supervisor in Pasadena, California at Imperial Management Administrators Services Inc

JOB DESCRIPTION

JOB TITLE: Claims Supervisor FLSA STATUS: Exempt

DEPARTMENT: Claims

REPORTS TO: Claims Director

AUTHORITY: PDR Claims Examiners

JOB SUMMARY: Oversees the daily activities of the PDR Claims Examiners. Assist the Claims Director and Claims Team in meeting departmental goals, assists with special projects, makes technical recommendations, monitors staff quality, hires new employees, and conducts new employee training.

ESSENTIAL JOB FUNCTIONS:

1. Manages responsibilities of PDR team.

2. Monitors inventory levels and aging of PDR claims and appropriately assigns work daily.

3. Review claims metric and quality reports and analyze monthly reports.

4. Understands in detail, the daily, weekly, monthly, and yearly metrics of the client needs and Claims Department and can adjust meet goals/objectives.

5. Responsible to participate in and oversee CMS, health plan audits/assessments, responses, and corrective action plans as it relates to clients.

6. Evaluates and makes recommendations on training material and methodology.

7. Conducts training for PDR new hires and any follow-up training that may be necessary.

8. Maintain a full comprehensive understanding of the client services, contractual requirements, Federal and State regulations, covered benefits, coding guidelines, reimbursement policies and provider contract terms.

9. Ensure all benefit, provider, fee schedules, and DOFR rules are established correctly and audited periodically to ensure compliance with contracts through review of contract configuration within EZ-Cap to assure accurate payments to providers.

10. Perform root-cause analysis that may cause PDR claims non-compliance/non-performance and lead, in collaboration with necessary operational departments, the implementation of resolutions.

11. Analyze operational impact and respond to complex escalated client and claims processing issues to ensure that client expectations and requirements are consistently met.

12. Review, create and or maintain workflows to ensure compliance and operational efficiency and develops and implements policies and procedures in collaboration with senior management.

13. Ensures PDR follows Federal and State regulations and has oversight of all health plan audits.

14. Develop the standard operation procedures (SOP), policies, procedures, and workflows that are needed to maintain strict control over PDRs Claims processing, Quality control, and Compliance.

15. Maintains regular and consistent attendance.

16. Adheres to Compliance Plan and HIPAA regulations.

MARGINAL JOB FUNCTIONS:

1. Takes on special projects as needed.

2. Performs other duties as assigned.

BEHAVIORAL EXPECTATIONS:

1. Continuous Learning:

a. Attends staff meetings as required.

b. Attends appropriate training, seminars and workshops as required

2. Customer Focus:

a. Maintains client/customer confidentiality and privacy in accordance with HIPPA regulations

and IMAS’s Standards of Conduct.

b. Fosters appropriate communication and relations with the Supervisor, co-workers, and other staff.

3. Quality/Process Improvement/Safety

a. Reports issues of security, health and/or safety to appropriate supervisor as soon as practicable.

b. Supports and demonstrates safety throughout all duties performed.

c. Follows established policies and procedures and understands and complies with all regulators

standards set forth by governing entities.

POSITION REQUIREMENTS:

EDUCATION/EXPERIENCE:

· Bachelor's Degree or the equivalent combination of training and experience is required.

· 5 years’ experience processing professional and facility healthcare claims.

· Must have at least 2-4 years of Supervisor level experience

SKILLS/KNOWLEDGE/ABILITY:

· Knowledge of Health Plan Claims Operations, Managed Care and Risk Bearing Organizations

· Knowledge of industry regulations, laws, policies, and regulations related to claims processing including CPT and ICD-10 guidelines.

· Knowledge of EZ-Cap claims processing workflows, steps, auto-adjudication rules is necessary.

· Advanced analytical skills demonstrated through the successful performance of numerous special analytical projects.

· Possesses analytical ability to work in a data-heavy environment and to identify trends in the data.

· Proficient in MS Office: Outlook, Excel (Pivot Tables) Word, and PowerPoint

· Willingness and ability to read, write, speak, understand English and have the communications skills necessary to provide accurate information to members and staff.

· Willingness and ability to follow written and verbal direction in English.

· Willingness and ability to maintain appropriate levels of confidentiality and privacy.

· Willingness and ability to interact professionally with all customers, members, and co-workers, individually and as part of a team.

· Willingness and ability to effectively handle multiple items/tasks as required and adapt favorably to changing priorities.

· Willingness and ability to make appropriate judgments, decisions and problem solving in a timely manner and within the context of the situation at hand.

· Willingness and ability to take initiative and be a self-starter.

· Willingness and ability to understand and comply with Federal, State, and local regulations.

LICENSURE/CERTIFICATE/TRAINING:

· n/a

JOB DESC