Claims Resolution Supervisor

Partnership HealthPlan of California•Fairfield, CA

About The Position

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.

Requirements

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

Responsibilities

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.
Coordinates with Claims Resolution Coordinators (CRCs) to develop provider educational/training materials for all Partnership lines
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.
Leads or participates in special projects and assignments as needed.
Participates in provider meetings, both on and off site as required.