Supervisor-Claims (Full-time hybrid, Morrisville, North Carolina Based)

Alliance Health•Durham, NC

8d•$69,592 - $88,729•Hybrid

About The Position

The Claims Supervisor oversees claims data entry, payments, credits, and adjustments; trains and develops Claims Research Analyst team members; audits claims performance; measures and maintains productivity; makes complex decisions; and analyzes information management systems. The position also provides guidance and oversight for training and technical assistance to provider agencies to strengthen the performance of Alliance’s provider partners. The successful candidate will work primarily remotely, with intermittent onsite requirements for training, onboarding, and team meetings. The role supervises claims operations, manages and develops staff, and collaborates with internal teams to support providers and successful claims processing.

Requirements

Bachelor’s degree from an accredited college or university in Business Administration or a related field.
Three years of claims leadership experience, with a focus on leading projects and people.
Ability to resolve complex problems requiring evaluation of alternative methods and solutions.
Ability to set objectives, delegate, and prioritize workflow.
Written and oral communication proficiency sufficient to handle projects and problems.
Ability to develop strong working relationships.
Proficiency in research techniques, statistical analysis, and report presentation.
Ability to make prompt decisions on complex matters and evaluate day-to-day operations.
Ability to prepare concise and accurate reports and plans.
Working knowledge of financial and budgeting systems.
Excellent customer service skills.
Knowledge of Medicaid and IPRS rules.

Nice To Haves

Experience in a behavioral healthcare agency.
Knowledge of CPT codes, Medicaid, and IPRS.

Responsibilities

Compile performance reports, monitor and record measures, and evaluate operational needs and workload requirements.
Execute and implement procedures and updates as directed by the Claims Manager or Senior Director.
Assess claims production and quality, monitor Provider and Member feedback, and ensure staff appropriately resolve claims, escalating issues when necessary.
Ensure the billing and reimbursement system is properly set up and maintained.
Review and analyze daily, weekly, and monthly reports to track processes, implement procedural and departmental changes to increase productivity, and monitor staff performance against department standards.
Stay current with regulatory, compliance, and departmental updates to meet departmental metric requirements.
Assist Claims Research Analysts in reviewing claim errors.
Develop, implement, and modify policies and procedures to ensure claims are valid and settlements comply with those policies and procedures.
Ensure providers are paid in accordance with prompt-pay guidelines.
Track assigned special projects and ensure completion by required dates.
Maintain provider relationships and obtain additional information as needed.
Identify inefficiencies and develop approaches to eliminate them.
Identify and support resolution of internal issues that create claims barriers for providers and Alliance.
Work with Human Resources and Claims leadership to attract, maintain, and retain a qualified, well-trained workforce.
Ensure staff are trained in and comply with organizational and departmental policies, procedures, and business processes.
Organize workflows and ensure staff understand their roles and responsibilities.
Ensure the department has the tools and resources needed to meet organizational goals, support employees, and comply with licensure, regulatory, and accreditation requirements.
Promote a positive, diverse, inclusive, respectful, and trusting work environment, applying standards transparently, consistently, impartially, and ethically.
Resolve conflicts and disputes while ensuring participants are heard.
Set performance goals and deadlines aligned with organizational goals and vision.
Communicate feedback and provide ongoing coaching and mentoring to staff, supporting learning and professional development.
Encourage cross-team collaboration and partnership.
Collaborate with Contracts, Credentialing, Enrollment, and Provider Network teams to help providers submit claims successfully; maintain working knowledge of Provider Network functions to guide providers on claims-related issues.
Collaborate with Utilization Management to resolve and manage system changes that support successful claims adjudication.
Participate in internal agency efforts that may include Peer Reviews, Data Analytics, Data Governance, Appeals, and Grievance Resolutions.