Supervisor, D-SNP Claims Processing / 788851527 (Administrative)

PRINCIPAL RESPONSIBILITIES:
Under the general direction of the Manager, Claims Production, the Dual Eligible Special Needs Plan (D-SNP) Claims Processing Supervisor is primarily responsible for the day-to-day supervision, direction, and guidance of Claims staff processing D-SNP claims, collaborating with other department Supervisors and other department leadership staff, as necessary, in order to meet and/or exceed performance targets. The D-SNP Claims Processing Supervisor will provide direct supervision to D-SNP Claims Processors but may also assist in the supervision of Claims Processors I, Claims Processors II, and/or Claims Processor III staff, as workloads allow.

The D-SNP Claims Processing Supervisor is responsible for ensuring that claims are received, processed, and adjudicated in a timely and accurate manner by communicating and enforcing department goals and objectives within a total quality management approach and in compliance with all applicable Medicare and/or Medi-Cal regulations. The Supervisor will oversee assigned production and workflow systems, monitoring and enforcing production and quality standards, ensuring compliance with all operating policies and procedures and claims processing guidelines, and collaborating with other departments to ensure the Alliances business, operating, and reporting goals are met.

Other principal responsibilities include:
Work with the Claims Production Manager to develop and implement unit production goals, then assign and monitor daily workload to ensure goals are achieved.Oversee the preparation of daily/weekly/monthly claims inventory and production reports.Respond to escalated provider claim inquiries received from Provider Services, as needed.Provide advice to other Alliance departments on claims related issues by phone, email or in person.Prepare, review, and approve staff timecards, approve/deny requested time off, and monitor attendance.Hire, coach and develop staff to accomplish departmental objectives. Monitor and provide feedback on staff performance, recognizing strengths, and coaching towards improved performance where necessary. Conduct scheduled performance appraisals in a timely and thoughtful manner.In conjunction with the Claims Trainer, assemble and maintain training materials and tools.Arrange for new or refresher training of staff, as needed.Review production metrics and assign work on a daily basis to staff.Conduct monthly one on ones with claims processors.Review Inventory, Quality, and Production reports weekly and coach staff towards improved performance, as necessary.In conjunction with Human Resources, develop Record of Meeting (ROM) and/or Improvement Action Plan (IAP) documentation, as necessary.Assist in the preparation for all internal, external, and regulatory audits.Perform other duties and special projects as assigned.

ESSENTIAL FUNCTIONS OF THE JOB
Ensure that D-SNP claims are paid in an accurate, timely manner and in accordance with Medicare, Medi-Cal, and Alliance regulations and guidelines.Ensure the processing of D-SNP claims adhere to regulatory requirements.Hire, train, lead, and evaluate claims production staff; build an effective team and assist in ensuring appropriate staffing and staff development.Identify opportunities for improvement in the D-SNP claims processing function and propose solutions.Identify problems, perform appropriate analysis, and determine options for resolution.Collect needed data, information, and/or analyses to assist in resolving complex claim issues and/or large volume claim adjustment projects.Produce reports on a daily, weekly, monthly, and/or ad hoc basis.Communicate effectively and efficiently, internally and externally, in written and verbal formats.In collaboration with the Claims Trainer and the Manager, Claims Operations Support, develop and maintain documented D-SNP claims procedures as a routine function.Respond to inquiries from other Alliance departments on D-SNP claims related issues via phone, email or in person.Lead and/or participate in internal committees and meetings.Comply with the organizations Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

PHYSICAL REQUIREMENTS
Constant and close visual work at desk or computer.Constant sitting and working at desk.Constant data entry using keyboard and/or mouse.Constant use of telephone headset.Constant verbal and written communication with staff and other business associates by telephone, correspondence, or in person.Frequent lifting of folders and various other objects weighing between 0 and 20 pounds. Frequent walking and standing.

Number of Employees Supervised: 5-10

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:
Bachelors degree or combination of education and equivalent work experience. High School Diploma or GED required.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
Seven years in a medical claim processing environment, preferably in Managed Care.Three plus years experience with D-SNP or Medicare Advantage guidelines in a managed care environment, including experience with all types of claims (professional, ancillary, facility).Three plus years experience with Medi-Cal guidelines and claims processing applications required, including experience with all types of claims (professional, ancillary, facility).Two years experience in a Supervisor, Lead, Trainer, Quality Assurance, or Auditor role highly preferred.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
Strong knowledge of Medicare policies and procedures.Must have detailed knowledge of CPT, HCPSC, MS-DRG, IPPS, OPPS, RBRVS, ICD-10, CMS1500/UB04 coding and forms.Experience with HIPAA and EDI transaction processing required.Previous experience as a Trainer or an Auditor in a claims environment desired.Excellent leadership, organizational, verbal and written communication skills, and problem-solving skills.Excellent customer service skills.A "hands-on" leader.Ability to develop, monitor, and adjust production standards.Well organized and detail oriented.Ability to handle multiple projects and balance competing priorities.Previous experience in a high-volume electronic claims processing system.Proficient experience in use of various computer system software including Windows, Microsoft Word, Excel, Outlook, Visio, and PowerPoint.Prior claims processing experience in RAM HealthSuite a plus.

SALARY RANGE $83,241.60 - $124,862.40 Annually
The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.