JOB SUMMARY

The Claims Supervisor performs activities to ensure claims related processes are executed according to standards, policies, procedures, regulations, laws, and guidelines.

ESSENTIAL FUNCTIONS

• Supervise daily operations and processes within the department by monitoring workflow and inventory, including distribution of work.
• Train, mentor, motivate, support, and oversee staff.
• Monitor departmental and individual performance metrics and take proactive action, when necessary, on a timely basis to maintain desired workflow outputs.
• Monitor vendor performance metrics and take proactive action, on a timely basis to maintain desired workflow outputs, when applicable.
• Develop and implement workflow changes to improve service and production efficiency of the department; this may include collaboration with other teams.
• Collaborate with other teams to implement new and revised policies and procedures, which may include suggested system changes or enhancements.
• Partner with internal and external contacts to achieve effective communications and maximum efficiency.
• May act as a liaison in monitoring and supporting specific topic or departmental assignments through reporting and relationship building.
• Select, develop, and evaluate staff to ensure the efficient operation of department.
• Demonstrate Company's Core Competencies and values held within.
• Participate in internal and external audits (i.e but not limited to Compliance, CMS, ASES, SOX, MTM, etc.)
• Stay up to date on local, state, and federal changes in regulations and laws to anticipate impact, new requirements, and potential changes in operational processes.
• Ensure legal compliance by following company policies, procedures, and guidelines as mandated by state and federal legislation and, or health plan or company directives. Alert non-compliance issues, coordinate and manage corrective action plans
• Oversight and, or act as SME on projects, initiatives and, or issues impacting claims operations and contribute with knowledge and experience. Research claim processing problems and errors to determine their origin and appropriate resolution.
• Manage and review complex and, or difficult claims or issues to determine best outcome.
• Prepares, maintain, and monitor productivity reports and presentations as required by management.
• Oversight all claims dependencies delegated to the different operational areas until full resolution to ensure the resolution of any incoming inquiries related to claims processes.
• Supervise and monitor the creation and submission of regulatory reports to ensure the compliance in a correct and timely manner and comply with metrics.
• Communicate with management regarding trends to improve claims processing accuracy.
• Document business rules for incorporation into training programs and assist with the training of new employee and vendor staff.

EDUCATION

EXPERIENCE

Bachelor’s Degree (BD) in Natural Science, Arts or Business Administration preferable with three (3) to five (5) years of experience in the Claims processing preferable in a health insurance industry analysis, investigation, auditing and/or risk management in a Healthcare setting.

LICENSES AND CERTIFICATIONS

COMPETENCIES