Claims Resolution Supervisor

2 days ago

Fairfield, California, United States Partnership HealthPlan of California Full time $93,690 - $117,113
Overview

Supervision of the Medi-Cal customer service outreach functions. Ensures delivery of the highest level of provider claims training to medical providers and the community.

Responsibilities
  • Coordinates with  Claims Resolution Coordinators (CRCs) to develop provider educational/training materials for all Partnership lines of
  • Prepares a quarterly and monthly plan of action for the Director, identifying key provider outreach targets and plan of
  • Prepares production statistics and related reports for the Director's revie
  • Collaborates with Claims Customer Service Manager to identify provider abrasion issues.
  • Leads group provider trainings or individual provider settings.
  • Reviews monthly reports and tracks claims trends for provider educational opportunit
  • Presents to Director with findings and recommendations for ongoing, long term resolutions
  • to Identifies items to address the "provider hassle factor."
  • Prepares a post-visit report for Director to include visit results, expectations of provider and Partnership, with required follow-up pla
  • Reviews, strategies and tactics for more effective communication to provider billing staff with CRC Recommends changes for more efficient communication.
  • Reports system issues to Claims Configuration staff and/or IT
  • Assists Provider Relations Manager and Representatives in the review, research, and resolution of complex provider inquiries, appeals, and
  • Coordinates  with   CRCs,   Claims,   and   Provider   Relations,   the development   and maintenance of ongoing educational materials and tips for inclusion on the Partnership
  • Reviews and  drafts  PR  newsletter  articles  related  to  claims  issues  identified  during provider training and research.
  • Interviews and participates in the selection of qualified candidates for CRCs. 
  • All other duties as as assigned. 

SECONDARY DUTIES AND RESPONSIBILITIES

  • Leads or participates in special projects and assignments as needed.
  • Participates in provider meetings, both on and off site as required.
Qualifications

Education and Experience

High School diploma or equivalent, minimum two (2) years of supervisor experience in a claims environment; or equivalent combination of education and experience.

Special Skills, Licenses and Certifications

Thorough knowledge of CPT, HCPCs procedure coding, and ICD-9 diagnostic coding. Knowledge of medical terminology. Expertise in automated claims procedures and related problems resolution. Typing speed 30 wpm and proficient use of 10-key calculator preferred. Valid California driver's license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business.

Performance Based Competencies

Excellent oral and written communication skills. Excellent interpersonal skills with ability to lead and manage staff to effectively complete assignments within established timeframes and standards. Ability to effectively exercise good judgment and handle sensitive issues with frequent interruptions. Good organization skills.

Work Environment And Physical Demands

Must be able to work in a fast-paced environment and maintain courtesy and composure when dealing with internal and external customers. More than 70% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying size, weighing up to 10 lbs.

All HealthPlan employees are expected to:

  • Provide the highest possible level of service to clients;
  • Promote teamwork and cooperative effort among employees;
  • Maintain safe practices; and
  • Abide by the HealthPlan's policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$93, $117,113.58

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

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