Supervisor, Claims Medi-Cal (Remote)

Position Summary/Position

The Medical Claims Supervisor 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)

1. Coordinate day-to-day claims operations tasks in accordance with established policies and procedures, standard operating procedures, and job aids to ensure optimal performance results.
2. 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.
3. Oversight of all aspects of departmental monitoring tools and controls to promote operational excellence.
4. Responsible for driving team results based upon established departmental quality and production performance metrics.
5. 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.
6. Develop strategies to improve upon departmental effectiveness and efficiencies. Identifies and implements process improvement opportunities that focus on customer value.
7. Serve as a subject matter expert and liaison with internal and external customers to address claim issues in an expeditious, accurate method.
8. Assist in formulating and executing initiatives to achieve departmental goals and objectives.
9. 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.
10. Assist Claims Management in identifying, creating, and implementing policies and procedures, standard operating procedures, and desk top references.
11. Make recommendations to leadership on changes and additions to department procedures through innovative thinking with an emphasis on automation.
12. Stay current with changes mandated by the regulatory agencies and industry standard processes.
13. 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.
14. Serves as a support to the Claim Operations Manager for absences, spike claim receipts, etc.

Major Functions (Duties and Responsibilities) Cont

Supervisory Responsibilities

Experience Qualifications

Four (4) years claims processing experience. At least two (2) years experience  in a supervisory capacity. Three (3) years experience in a managed care environment.  Experienced in benefit and financial matrix interpretation.

Preferred Experience

Experience preferably in an HMO or Managed Care setting. Medicare and/or Medi-Cal experience preferred. Prior experience in a lead role or customer service environment is a plus.

Education Qualifications

Bachelor's degree from an accredited institution required.

In lieu of the required degree, a minimum of eight (8) years of additional relevant work experience in a Managed Care or Health Care environment is required for this position. This experience is in addition to the minimum years listed in the Experience Requirements above.

Preferred Education

Professional Certification

Professional Licenses

Drivers License Required

Knowledge Requirement

Knowledgeable in CMS, DHMC and DHCS regulatory guidelines. Extensive knowledge of ICD-9, ICD-10, CPT, and Revenue Codes. Solid understanding of the DHCS, CMS rules and regulations governing claims adjudication practices and procedures desired.  Principles and techniques of supervision and training.

Skills Requirement

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.

Abilities Requirement

Must have a high degree of patience.

Commitment to Team Culture

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions

Data entry involving computer keyboard and screens, filing and copying of records and/or correspondence

Work Model Location

Physical Requirements