Supervisor, Claims Medi-Cal

Date: Jan 24, 2023

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 8508 

 

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

Leader: Administers Hires, Terminations, and Performance Reviews

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

No

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

Telecommute

Physical Requirements

Hearing: One-on-One - FREQUENTLY
Communicate: Information/ideas verbally - FREQUENTLY
Near Visual Acuity - FREQUENTLY
Regular contacts: co-workers, supervisor - FREQUENTLY
Memory - FREQUENTLY
Understand and follow direction - FREQUENTLY
Regular and reliable attendance - CONSTANTLY
Keyboarding: 10-Key - FREQUENTLY
Keyboarding: Touch-Screen - FREQUENTLY
Keyboarding: Traditional - FREQUENTLY
Sitting - CONSTANTLY
Indoors - FREQUENTLY
Lighting - CONSTANTLY

A reasonable salary expectation is between $70,012.80 and $89,273.60, based upon experience and internal equity.

Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region, designated as “Great Place to Work.” With a provider network of more than 5,000 and a team of more than 3,000 employees, IEHP provides quality, accessible healthcare services to more than 1.5 million members. And our Mission, Vision, and Values help guide us in the development of innovative programs and the creation of an award-winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and make a difference with us! IEHP offers a competitive salary and stellar benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles