Job: Claims Supervisor

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Job Description

Claims Supervisor


Daily Schedule-Days
Scheduled Hours per 2-week Pay Period-80
Weekends Required -None


The primary role of theClaims Supervisor is to supervise the overall performance of the Claims Team.This position is responsible for documenting processes and managing day to dayworkflows to ensure compliance with all CMS requirements, state requirementsand QualChoice Health standards regarding the processing of Claims, refundchecks, advances.  Oversight of relationship with BMS and offshoreteam.


Essential Duties andResponsibilities

·        Serve aspoint of escalation for issues that Claim Analysts are unable to resolve.

·        Developprocedures, workflows, training and sharing of best practices.

·        Ensuresthat information is processed accurately and appropriately.

·        Providesguidance to Claims staff.

·        Ensure staff is knowledgeable of all MedicareAdvantage products and services offered.

·        Representthe Claims Team in cross-functional meetings and committees when needed.

·        Communicatewith other departments and staff in order to increase understanding, distributeinformation and resolve Claims issues.

·        Supportcorporate quality improvement processes and ensure compliance with regulatory,accreditation, and health plan standards, including support with auditprocesses, CMS data validation audit and other audit needs as theyarise.  Work with Network Team and Provider Relations Team to addressany concerns.  Be point for Claims questions and projects.

·        SupportAnnual Enrollment Period activities, including review and updating of anymaterials.

·        Maintainconfidentiality of provider and employee information.

·        Fosterstrong professional working relationships with others in the company, delegatesand external agencies to aid in the implementation of cross-functionalcooperation and improvement of interdepartmental processes.

·        RepresentQualChoice Health in a courteous manner in attitude and appearance, behavingethically and using a professional demeanor in oral and written communicationswith internal and external customers.

·        Adhereto all company compliance standards.

·        Performother duties as required or assigned.


Education and Experience

·        High School Diploma required; Undergraduate degree preferred

·        5+ years of industry experience in Claims processing.

·        Comprehensive knowledge of CMS regulations and requirements as related to Claims.

·        Must possess strong problem-solving skills, project management and negotiation skills and have the ability to multi-task in an effective and organized manner.

·        Ability to establish and maintain good working relationships with staff, external customers and government agencies, as necessary.

·        Familiarity and understanding of claims payment and care management systems, general health plan operations, and benefit plans.

·        Experience working in Medicare, Medicare Managed Care, and Medical Terminology.


Certificates, Licenses and Registrations

·        Reliable transportation, auto insurance and a valid driver’s license required

We’re an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.  

Requisition Title

QualChoice Health