Centers Plan for Healthy Living

Claims Supervisor

US-NY-Staten Island
4 months ago
ID
2017-1199
# of Openings
1
Category
Claims

Overview

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JOB SUMMARY:

 

Responsible for supervision and oversight of the Claims Processing unit of Centers Plan for Healthy Living (CPHL) in accordance with CPHL workflow, policies, state and federal standards. 

Responsibilities

PRIMARY RESPONSIBILITIES: 

 

  • Supervises staff to ensure claims are processed accurately, within regulatory timeframes and individual performance goals while adhering to department, industry and productivity standards. Schedules daily work assignments and assists staff in the solution of problem claims. 
  • Develops indicators, monitoring tools and reporting mechanisms to support all areas of the claims department. Reviews and analyzes weekly and monthly department performance reports.  Escalates department performance issues and recommends or implements needed interventions.
  • Handles escalated claim related complaints. Communicates with the appropriate parties to obtain and impart information to resolve problem claims. Researches and reviews all claim discrepancies to determine source of errors.
  • Supports claims processing by developing and analyzing data, implementing quality improvement measures, and interfacing with other CPHL departments to improve claim processing.
  • Communicates with providers regarding unpaid claims and billing procedures. Collaborates with Provider Relations to educate providers regarding common claim issues and to resolve particular claim-related provider issues.
  • Interfaces with Claim System Vendor/BPO to research problem claims, clarify procedures and to identify any problem trends.  Assists Director in monitoring BPO and related activities pertaining to BPO claims processes, configuration and claims operations.
  • Develops workflows, policies and procedures for the claims department and understands how they relate to other CPHL policy and procedures.
  • Provides training on claims processing to staff as needed.
  • Maintains a working knowledge of all Medicare and Medicaid coverage issues as they relate to CPHL products.
  • Performs all duties inherent in a supervisory role.  Ensures effective staff training, evaluates and communicates staff performance, provides input for the development of staff.
  • Participates in special projects and perform other duties, as assigned.

 

 

Qualifications

EDUCATION AND EXPERIENCE:

 

Education

Required:  Bachelor's Degree in Business Administration or related field required.

 

 

Type of Experience

Required:  Minimum three to five years' experience in business/insurance setting, of which three years must be in Medicare and Medicaid claims department.  Minimum two years supervisory experience required.

 

 

Specific Technical Skills

Required: Proficiency with a claims processing system required.  Proficient PC skills, including Microsoft Office Products such as Excel, Access, Word and PowerPoint required.  Proficient use of Microsoft Access.

Preferred:  Knowledge creating queries using Access data bases or other SQL based products.

 

 

Certifications/Licensure

Required:   n/a

 

 

Knowledge ans Skills:

  • Effective presentation skills.
  • Excellent verbal and written communication skills.
  • Must be able to participate in meetings with all levels of management within the organization.
  • Detail Orientated, excellent follow up.
  • Ability to multi-task in a fast paced environment.
  • Must be service orientated, quick learner, team player.
  • Appreciation of cultural diversity and sensitivity toward target population.

 

PHYSICAL REQUIREMENTS:

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Must be able to travel within the five boroughs, Rockland, Erie and Niagara.

The above statements are intended to describe the general nature and level of work performed by individuals assigned to the job classification.  They should not be constructed as an exhaustive list of all responsibilities, duties and skills required.

 

 

 

 

 

 

 

 

 

 

 

 

 

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