Supervisor Claims Operations

The Supervisor Leads claims production team ensuring accurate timely and compliant adjudication while developing staff reducing errors and overpayments and advancing organizational quality and financial goals.

What Youll Do

• Monitor and review work of all Claims production staff to identify additional training needs and to ensure compliance with department quality and production standards. Provide performance feedback and identify developmental opportunities for Claims staff.
• Monitor and review claims production and transaction reports. Identify claims error trends and implement controls and changes that will minimize incorrect claims adjudication. Coordinate potential recovery efforts with Company Accounting and coordinate potential physician education opportunities with Company Physician Services.
• Work closely with other Company departments to ensure that all areas supporting claims meet appropriate claims quality goals.
• Ensure that all legal regulatory and policy requirements are met by keeping informed of changes and implementing necessary controls and/or programs to meet requirements.
• Manage and update claims production policies workflows and processes to ensure compliance with Claims department and State Federal and Health Plan quality standards. Provide analysis of claims quality adjudication results and identify training opportunities for the Claims team.
• In collaboration with the Claims QA and Training Specialist Supervisor ensure that Claims Representatives have a thorough understanding of Company claims adjudication policies and procedures.
• Coordinate provider contract health plan benefit/DOFR and system rules configuration testing with the Business Applications Configuration team.
• Ensure accurate reporting and timely submission of quarterly PDR timeliness reports.
• Prepare coordinate and facilitate external party PDR and adjustment audits. Develop any corrective action plans (CAPs) that result from PDR and adjustment audit findings and monitor progress and application of documented CAPs.
• Work with Company departments on implementing controls to minimize claims overpayments and identify physician education opportunities with Network Management.
• Work closely with other Company departments and specifically the Claims QA and Training Specialist to communicate findings of recovery audits and to facilitate accurate adjudication of claims.
• Supervise direct reports by assigning and directing work; conducting employee evaluations staff training and development; taking appropriate disciplinary/corrective actions; and making hiring/termination recommendations. Mentor team members in both technical and functional areas to provide growth opportunities.
• Accountable for achieving departmental goals related to claims inventory turnaround times quality scores production standards and financial accuracy.
• Other duties as assigned.

Qualifications

Education

• Bachelors degree in a relevant field (or an equivalent combination of education and progressively responsible experience).

Experience

• At least 5 years of medical claims experience with a Medical Group IPA MSO or Health Plan.
• At least 2 years of lead supervisory or people leadership experience preferred.
• Experience must be in healthcare claims; experience in workers compensation life insurance or auto insurance does not count toward the minimum requirement.

Knowledge Skills & Abilities

• Advanced knowledge of and hands-on experience with healthcare coding conventions including ICD-10 CPT and HCPCS.
• Thorough knowledge of medical claim processing procedures and systems including auditing claim protocols industry standards and CMS regulations related to claims payment and compliance.
• Advanced knowledge of claims processing system configuration and architecture sufficient to troubleshoot complex claims transaction issues.

Environmental Job Requirements and Working Conditions

• Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Drive Monterey Park CA 91754.
• The total compensation target pay range for this role is between $78000 - $91000. Actual compensation will be determined based on geographic location (current or future) experience and other job-related factors.

Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race religion color national origin gender (including pregnancy childbirth or related medical conditions) sexual orientation gender identity gender expression age status as a protected veteran status as an individual with a disability or other applicable legally protected characteristics. All employment is decided on the basis of qualifications merit and business need. If you require assistance in applying for open positions due to a disability please email us at to request an accommodation.

Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.

Required Experience:

Manager