Claim Services Supervisor

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Claim Services Supervisor

Department: Claim Services

FLSA Status: Full Time, Exempt

Salary Level: 1Mgmnt

Position Summary:

Responsible for assisting in the day-to-day management of the Claims Services department primarily focusing on the following:

• Planning, organizing, monitoring, and evaluating staffing requirements.
• Supervise, train, and evaluate the Claims Services Associates performance.
• Monitoring claims inventory and monitoring compliance with the established performance standards for claims turnaround and payment accuracy
• Training staff, compiling daily workflow reports, tracking claims inventory, system tests, and processing complex and special handle claims
• Serves as the backup to the Claim Services Manager in his/her absence.
• Active participation in Performance Improvement projects to assure that UHA fulfills its commitment to continually improve its performance and achieve the goals of the annual business plan
• Requires excellent written, verbal and interpersonal communication skills.
• Must understand and carry out oral and written communication.
• Interpersonal Skills: Must remain open to others’ ideas and exhibit a willingness to try new things.
• Oral communication: Must speak clearly and persuasively in positive or negative situations.
• Written Communication: Must edit work for spelling and grammar, present numerical data effectively and is able to read and interpret written information.
• Strives to continuously develop the Twelve Characteristics and Competencies of the ideal UHA leader.

Essential Duties & Responsibilities:

Training

• Prepare written training plan to set daily and weekly goals for new associates or temporary help.
• Assist the Claim Services Manager in developing and documenting clear processes and procedures.
• Participate in Catalytic Coaching and collaborate with each Claims Processor by coming up with Focus Areas to achieve and having regular coaching sessions as needed.
• Assist the Claim Services Manager in updating reports that monitor the departments daily and weekly results of production for quantity and quality.

Section Operating Report

• Assist Claim Services Manager in completing the Section Operating Report (SOR) daily to track incoming claims, production, and inventory to ensure that production and inventory levels are meeting department standards.
• Consistently maintain an acceptable low pended claims inventory that can be easily tracked daily, weekly, and monthly.

Claims Processing

• Assist Claim Services Manager with reviewing and processing special handle claim cases, includes Member Cost Transparency Notice (MCTN) and Letter of Agreement (LOA) cases for out of state and/or transplant services cases.
• Process high-cost inpatient claims in accordance with the Inpatient High Cost Claims Policy. Refer difficult or questionable cases to the Claim Services Manager.
• Helps process Special Handle Medical Claims
• Handles Third Party Liability (TPL) cases. Create claims processing system memo to identify, track and pay or deny claims in accordance with the Third Party Liability policy and medical benefits guide.
• In the absence of the Claim Services Manager re-process previously denied inpatient claims.
• Coordinating processes with Out of State Participating Provider Network. Accessing the contracted provider’s web-based re-pricing network to manually price within the contracted turnaround time. from date of receipt of submitted claim.
• Processing of CMS 1500 and UB04 EDI and paper claims that meets or exceeds established quality level based on individual performance.
• Monitor claims turnaround time for electronic and paper claims to process within set company and department time frames that follow the Clean Claims Act.
• Review and process any high-level claims when needed.
• Analyzing and calculating coordination of benefit payments based on NAIC rules.

System Testing

• Review and compare data entry & processing response time, contract and benefit edits, accumulators, payment outcome, and accessibility to other modules.
• Develop and document clear written procedures to help define each Claims Processing tasks to help achieve the department goals.

Other Duties/Functions

• Attendance is a major function of the job.
• Perform other duties as assigned and asking for additional duties when workload permits.
• Ensure timesheets are consistently accurate and complete for each pay period.
• Model healthy behaviors.
• Active participation in Performance Improvement projects to assure that UHA fulfills its commitment to continually improve its performance and achieve the goals of the annual business plan

Required Education and Experience:

The individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Associate degree from an accredited university, two years college level, or specialized business school training or 2 years of management or supervisory experience
• Proficient in medical terminology, medical billing, and medical coding
• Minimum three years of work experience associated with medical claims filing or processing

Preferred and Advanced Qualifications:

• Able to interpret group benefit plan coverages.
• Able to analyze and calculate Coordination of Benefits information.
• Thorough knowledge of the medical claims and drug claims processing software applications
• Able to work as a contributing team member towards achieving managements stated goals.
• CPC (Certified Professional Coder) certification or equivalent medical certification

Physical Demands/Working Conditions:

The work environment characteristics described here are representative of those associate encounters while performing the essential functions of this job.

This position is eligible to work from home upon management’s approval

Competitive compensation & excellent benefits offered

Visit our website at https://uhahealth.com/page/career-opportunities to apply and for details about vacant positions.

An Equal Opportunity Employer