Supervisor, Claims BPO Operations

CHPW•Seattle, WA

About The Position

This position is responsible for supervision and leadership for BPO Operations including direct management of staff, cross-departmental coordination and vendor relationship management. Supports the interface between Community Health Plan of Washington (CHPW) and vendors (third party administrators) for claims benefit system configuration and third-party administration (TPA). Manages business requirement development, configuration, user testing, workflow, quality assurance, production support, escalated claims/provider issues, encounter data, new product implementation, electronic data files, fee schedules/rates, provider contract templates and third-party administration for claims and billing. Project management, develop and execute process improvement, root cause analysis and remediation.

Requirements

Bachelor’s degree in health care or an equivalent combination of education and highly equivalent experience required.
Minimum five (5) years’ managed care/health plan operations experience required.
Minimum four (4) years’ leadership (supervisory/management) experience in a related field, required.
Experience overseeing healthcare claims operations, including benefits administration, system configuration, and implementation of complex provider rates, pricing methodologies, fee schedules, clearing house administration.
Proven leadership in managing professional and institutional claims within thirdâparty administration environments, ensuring accuracy, compliance, and operational excellence.
Background in Medicaid, Medicare, OIC claims administration, benefit interpretation predilection for process improvement, identifying, planning and executing appropriate strategies, methodologies and activities to achieve team and company goals.
Complete and successfully pass a criminal background check
Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.
Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency
Vaccination requirement (CHPW offers a process for medical or religious exemptions)
Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.
Knowledge of quality improvement methods and tools.
Project management, team facilitation, and communication skills, both verbal and written.
Analytical, technical, problem-solving, and process documentation skills.
Ability to multi-task, prioritize, and work under pressure.
Ability to build collaborative relationships throughout the organization, with CHPW vendors, and with state and federal agencies.

Nice To Haves

Minimum three (3) years’ experience as a Senior Operations Analyst at CHPW, preferred.

Responsibilities

Responsible for the direct supervision of Operations staff, including interviewing, hiring, performance management, time keeping records, training, coaching and employee development.
Building a cohesive, empowered and productive work environment.
Responsible for improving production processes and quality on a continuous basis.
Manage prioritization of system configuration, testing and implementation activities involving claims and encounter data.
Facilitate the development and execution of user acceptance scenarios and scripts for testing system changes and enhancements.
Manage claims and billing Clearinghouse (TPA) for Medicaid programs.
Oversee endâtoâend claims and billing operations with the TPA for Medicaid programs, ensuring accuracy, efficiency, and alignment with program requirements.
Provide strategic guidance to providers on claims preparation and submission, including developing training materials and enabling process improvements.
Ensure timely and compliant submission of all required program documentation, maintaining strong operational controls.
Lead oversight of clearinghouse claim workflows, including escalation management, technical issue resolution, and rootâcause analysis for provider rejections.
Drive program compliance and performance through rigorous monitoring, reporting, and continuous improvement initiatives.
Regularly monitor departmental contractual compliance with state, CMS, OIC requirements (claims benefit configuration, claims timeliness, claim denials, encounter data submissions, clearing house); including supporting the collection and submission of required operational performance metrics and data reporting requirements.
Provide oversight including SLA reporting and audit to Operations’ assigned vendors.
Lead the analysis and documentation of business process workflows, policies and procedures for Operations.
Act as the subject matter expert for Operations in companywide or specific projects, including configuration on vendor systems.
Monitor the performance of processes within the Operations Department identifying improvement strategies and interventions when targets are not met.
Lead and guide process owners and internal stakeholders in the planning and execution of process improvement activities including identifying suitable strategies, methodologies and interventions necessary to achieve desired outcomes.
Take a leadership role working with project teams to develop and track key performance targets and metrics to effectively monitor improvement activities and interventions.
Regularly report results to management and project owners.
Participate in and oversee the work involved in a variety of audits including TEAMonitor, HEDIS, NCQA, CMS, Internal audit.

Benefits

Medical, Prescription, Dental, and Vision
Telehealth app
Flexible Spending Accounts, Health Savings Accounts
Basic Life AD&D, Short and Long-Term Disability
Voluntary Life, Critical Care, and Long-Term Care Insurance
401(k) Retirement and generous employer match effective the 1st of the month following or coinciding with the employee’s start date
Wellness programs (Employee Assistance Program and Mental Fitness app)
Financial Coaching, Identity Theft Protection
Paid Time Off (PTO) including PTO accrual starting at 17 days per year
40 hours Community Service volunteer time
10 standard holidays, 2 floating holidays
Compassion time off, jury duty
A monthly stipend to offset work-from-home expenses for roles that are 100% remote