Claims Operations Supervisor

Supervises data collection/interpretation by providing guidance and support to others on implementing required system configuration changes, monitoring and guiding others on inputting claims details into claims database, and identifying and recommending resources to aid the maintenance and quality of data in KP systems. Ensures the team abides by protocols when collecting referral data, provides direction to others who verify referrals/or authorizations, and oversees the submission of audit reports. Ensures their team is knowledgeable of compliance protocols and provides clarification on relevant compliance standards, regulatory policies, laws, or accreditation standards. Directs and plans the work of teams for strategic projects, provides analysis support in response to process/system issues, recommends ways to improve operating efficiency, and implements performance metrics. Supervises member identification/support processes by directing the processing of insurance claims, assigning and providing guidance to team members to develop solutions to claims and benefits inquiries.

• Recommends developmental opportunities for others; builds collaborative, cross-functional relationships. Solicits and acts on performance feedback; provides team members with feedback; and mentors and coaches to drive performance improvement. Pursues professional growth; provides training and development to talent for growth opportunities; supports execution of performance management guidelines and expectations. Implements, adapts, and stays up to date with organizational change, challenges, feedback, best practices and processes. Fosters open dialogue, supports, mentors, engages, and motivates team members on collaboration. Delegates tasks and decisions as appropriate; provides appropriate support, guidance and scope.


• Supervises and coordinates daily activities of designated work team or unit by monitoring the execution and completion of tactical action items and work assignments; ensures all policies and procedures are followed. Aligns team efforts and standards, and measures progress in achieving results; determines and carries out processes and methodologies; resolves escalated issues as appropriate. Develops work plans to meet business priorities and deadlines; coordinates, obtains and distributes resources. Removes obstacles that impact performance; identifies and recommends improvement opportunities; influences teams to execute in alignment with operational objectives.


• Supervises the payment of claims by: overseeing team performance on the review and to ensure that all expenditures are properly adjudicated and paid on time in accordance with contractual benefits; and providing guidance and oversight on the communication of claims information (e.g. pay decisions, referral matching) to adjudicators, vendors, and stakeholders on payment approval/denial and provides guidance on addressing escalated claims payment issues.


• Provides oversight for compliance by: ensuring their team is knowledgeable of policies and procedures which support compliance protocols; providing guidance to their team members to clarify relevant documentation, policies, and processes related to referrals, authorization processes, and utilization review; using thorough knowledge of claims processing practices to ensure relevant compliance standards, regulatory policies, laws, or accreditation standards are incorporated into training; and collecting and conducting data analysis and report development of claims activity for submission to appropriate regulatory bodies.


• Supervises data collection/interpretation by: providing guidance and support to others on implementing required system configuration changes, reviewing completed system configurations to ensure they are error-free; monitoring or guiding others who are inputting, reviewing, or auditing claims data in data in claims databases across various regions; and aligning teams on methods to create and maintain databases and automated tools which improve workflow.


• Supports member identification/support processes as directed by: providing guidance to others on researching and addressing escalated inquiries regarding claims-payment issues or provider disputes; and assigning and providing guidance to team members to develop resolutions that should be proposed to providers and members when addressing claims and benefits inquiries.


• Oversees improvements to operations and technology processes by: directing and planning the work of teams on strategic projects designed to remediate issues for impacted groups and improve claims and referral operating efficiency; providing analysis support on claims and referral processes in response to claim escalations to improve the performance of claims, referral, or other system processes; and implementing performance metrics to track the success of strategic improvement projects.


• Supervises the intake and management of referral requests by: exercising judgment and discretion on methods to collect inpatient medical data (e.g., charts, records) from internal staff or clinicians, outside providers, and members to determine coverage/benefits and make a referral; ensuring the team remains compliant with privacy laws and abides by protocols when entering patient data (e.g., admission, discharge, electronic medical record, demographic) in the referral system so that providers can ensure coordination of care; and reviewing and providing feedback on completed, complex reports; and holding the team accountable for completing and submitting audit reports to ensure referrals have been processed according to quality standards.

Qualifications:

• Minimum one (1) year of experience managing operational or project budgets.


• Minimum three (3) years of experience in a leadership role with or without direct reports.


• Minimum two (2) years of experience in Referral Services, Claims Membership, Medical Claims, Contracting with Medical Providers, Referral Processing, Authorization/Referral Claims Administration or a directly related field.


• Bachelors degree in General Studies, Nursing, Public Health, Social Work, Medicare, Computer Science, Health Care Administration, Business, Health Plan Administration, Insurance Administration, Finance, Pharmacy, or related field AND minimum three (3) years of experience in Claims Consulting, Referral Claims Administration, Customer Service, Automated Claims Systems, Administrative Services, or a directly related field OR Minimum six (6) years of experience in referral processing, authorization/referral claims administration, administrative services, customer service or a directly related field.

• Knowledge, Skills, and Abilities (KSAs): Business Operations; Audits; Compliance Management; Internal Controls; Data Stewardship; Regulatory Reporting; Financial Analysis; Health Care Coding; Customer Experience; Computer Literacy; Insurance Coding; Insurance; Contract Review & Claims Validation; Claims Applications