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L.A. Care Health Plan · 13 hours ago

Supervisor, Claims

Los Angeles, CA

Full-time

Onsite

Mid, Senior Level

$77K/yr - $124K/yr

5+ years exp

L.A. Care Health Plan is the nation’s largest publicly operated health plan, dedicated to providing health coverage to low-income residents in Los Angeles County. The Claims Supervisor will oversee daily operations in the claims department, ensuring compliance with regulations and maintaining quality performance standards.

FitnessGovernmentHealth Care

Responsibilities

Provide an environment that allows staff members to flourish in their work duties

Quality levels of 99% maintained throughout the department

Continuous training of supervisors on supervisory responsibilities as well as staff training on all enhancements and updates to claims regulations and company policies

Develop procedure changes to improve results

Corrective action plans developed and implemented to remediate any shortcomings in goal achievement

Maintain quality goals and production levels within the Department

Ensure that Claims Department Supervisors are working effectively with their staff to ensure quality and production goals associated with each work area are consistently met by staff during their regularly scheduled work hours

Create, maintain and monitor departmental documents including policies, procedures, desktop procedures, workflow documents and job aids to ensure these documents are current and meet the requirements of L.A. Care

Track and trend the metrics associated with the claims adjudication

Prepare and present written and verbal reports

Research complex problem areas within the department or within the systems used by department, and identify the root cause of these issues and recommend corrective actions

Supervise staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others

Perform other duties as assigned

Qualification

Claims examinationHealthcare codingData analysisMicrosoft WordMicrosoft ExcelCoaching skillsMulti-taskingTeam buildingWritten communicationVerbal communicationProblem-solving

Required

Bachelor's Degree in Business or Healthcare Related Field

At least 3 years of experience as claims examiner working with medical facility claims and high dollar claims

At least 2 years of leading process, program, or staff or supervisory experience

Experienced in working with Provider Dispute Resolution (PDR's)

Must have extensive experience in handling claims appeals with experience in communicating with external providers

Sound understanding of health care code sets including Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), ICD-10 and revenue codes required

Familiarity with Diagnosis Related Group (DRG) pricing

Ability to multi-task in a high production environment

Familiarity in working with and interpreting Provider and facility contracts and LOA's and MOU's

Ability to draw conclusions from data analysis and to formulate corrective action plans when necessary

Proficient in using Microsoft Word and Excel

Must have strong coaching and mentoring skills and have the ability to build effective teams

Must have excellent written and verbal communication skills with ability to work effectively with diverse team members

Ability to research complex claims problems and to create clear and concise procedures for the handling of complex claims