Job Description

Claims Supervisor

Summary: Under the supervision of the Claims Manager, the Claims Supervisor is responsible for providing support, direction and supervision to Claims Examiners. This position also monitors and supervises various processes throughout the claims cycle and may process claims for assigned groups.

Essential Functions:

• Supervision and Leadership
•  Responds to examiner questions and tracks question trends
•  Assists with providing training for new and existing examiners and assistants
•  Provides ongoing feedback and support to improve performance of direct reports
•  Prepares and facilitates performance reviews for direct reports
•  Reviews and approves time cards and PTO requests for direct reports
•  Assists with the identification and selection of new employees
•  Communicates clearly and concisely, with sensitivity to the needs of others

Claims 

•  Monitors claims inventory daily; manages inventory to ensure claims are being processed in a timely manner
•  Processes overpayments, underpayments, and refund checks
•  Reviews appeals and assists with determination
•  Reviews and approves weekly claim batches
•  Monitors weekly pend report process
•  Monitors weekly pre-check register process
•  Assists with researching escalated provider services/client services claims inquiries
•  Assists with organization and facilitation of department meetings

Additional Functions: 

•  Assists with special projects, as requested
•  Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees
• Maintains courteous, helpful and professional behavior on the job
•  Establishes and maintains effective working relationships with co-workers
•  Follows and ensures departmental compliance with all Policies and Procedures and HIPAA regulations
•  Maintains knowledge and understanding of current Medicare claims processing guidelines
•  Attends continuing education seminars/training as requested
•  Maintains a safe working environment
• Supervisory Responsibility: Provides supervision for assigned remote Claims Examiners.

Travel:  None

Knowledge, Skills and Abilities:

•  Educational requirements include a High School Diploma or equivalent. A minimum of three years of claims processing experience is preferred. A minimum of one year of supervisory experience is required, preferably in health plan operations.
•  Solid understanding of CMS-1500 & UB-04 guidelines
•  Strong working knowledge of CPT, ICD-10, and HCPCS coding, including modifiers
•  Familiarity with APC and DRG reimbursement
•  Knowledge of EDI claims
•  Knowledge and experience using current computer technology, including experience with Excel and Word.
•  Skilled in establishing and maintaining effective working relationships with clients, and staff at all levels
•  Skilled in data analysis and problem solving using defined methodologies
•  Skilled in problem resolution; recommends suggestions to increase accuracy and/or efficiency
•  Ability to be an advocate of the 32 Fundamentals
•  Ability to work independently with minimal supervision
•  Ability to independently follow through on projects
•  Ability to communicate professionally, clearly and effectively, verbally and in writing
•  Ability to prioritize effectively
•  Ability to consistently multitask

Physical Demands & Requirements :

•  Communicates in person and via telephone with staff, participants, customers, and vendors
•  Operates a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer
•  Remains stationary for extended periods of time
•  Occasionally exerts up to 20 pounds of force to lift, carry, push, pull or move objects
•  Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy
•  Occasional reaching to retrieve shelved items

 Occasional bending/stooping

Work Environment :

•  This job operates in a home office environment
•  No substantial exposure to adverse environmental conditions is expected.
•  Moderate pressure to meet scheduled appointments and deadlines

Supervised by:    Claims Manager

Skills

PRIMARY COMPETENCY : Healthcare PRIMARY SKILL : Non-Voice PRIMARY SKILL PERCENTAGE : 100