Supervisor, Provider Claims Resolution & Recovery - Claims

Position Summary/Position

Monitors daily activity of assigned inventories, including disputes, appeals, adjustments, special projects, and outgoing correspondence. Reviews special projects and delegate to appropriate units for processing. Supervises Claims Appeals Resolution team members including questions, productivity, quality, attendance, and performance evaluations. Establishes and delegates work assignments according to team member job specifications and business needs. Assists with handling escalated phone calls, adjustments, disputes, appeals, or training needs as required. Identifies trends in dispute and or payment issues and facilitate internal awareness to initiate a coordinated effort across claims units for education and improvement of accuracy. Communicates with Providers regarding claims payment inquiries, disputes, or appeals. Generates daily/periodic inventory control reports, regulatory reporting compliance. Coordinate with other IEHP departments to facilitate resolution of claim-related issues. Identify and report claim-related billing issues to various departments for follow-up provider education. Regulatory audit preparation and research complex claims as needed.

Major Functions (Duties and Responsibilities)

1. Monitors daily activity of assigned inventories, including disputes, appeals, adjustments, special projects, and outgoing correspondence.
2. Review special projects and delegate to appropriate units for processing.
3. Supervises Claims Appeals Resolution team members including questions, productivity, quality, attendance, and performance evaluations.
4. Establish and delegate work assignments according to team member job specifications and business needs.
5. Assists with handling escalated phone calls, adjustments, disputes, appeals, or training needs as required.
6. Recognize trends in dispute and or payment issues and facilitate internal awareness to initiate a coordinated effort across claims units for education and improvement of accuracy.
7. Communicate with Providers regarding claims payment inquiries, disputes, or appeals.
8. Generate daily/periodic inventory control reports, regulatory reporting compliance.
9. Serves as liaison between IEHP and its delegated entities for provider claim appeals received.
10. Coordinate with other IEHP departments to facilitate resolution of claim-related issues.
11. Identify and report claim-related billing issues to various departments for follow-up provider education.
12. Assist with audit preparation and research complex claims as needed.
13. Attend key strategic meetings that are necessary to maintain a viable knowledge base within the team.

Major Functions (Duties and Responsibilities) Cont

Supervisory Responsibilities

Experience Qualifications

Four (4) years of experience in a Managed Care environment in the areas of claims processing, and or provider payment appeals and disputes, with at least one (1) year in a supervisory capacity.

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

High School Diploma or GED required.

Preferred Education

Professional Certification

Professional Licenses

Drivers License Required

Knowledge Requirement

Extensive knowledge of ICD9, CPT and Revenue Codes. Knowledgeable in CMS, DHMC and DHCS regulatory guidelines, including AB1455.  Principles and techniques of supervision and training. A thorough understanding of claims industry and customer service standards.

Skills Requirement

Strong analytical and problem-solving skills. Microsoft Office, Advanced Microsoft Excel. Analytical skills with emphasis on time management, database maintenance, spreadsheet manipulation, and problem solving.  Strong writing, organizational, project management proficiency required. Must have excellent interpersonal and communication skills.

Abilities Requirement

Ability to build successful relationships across the organization. Excellent oral and written communication skills. 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

Sedentary work in an office enviornment.

Position is eligible for Hybrid work location upon completing the necessary steps and receiving HR approval. All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership.

Work Model Location

Physical Requirements