Supervisor - Claims Delegation Oversight

Astrana Health, Inc.•Monterey Park, CA

10d•$78,000 - $91,000•Hybrid

About The Position

The Supervisor, Claims Delegation Oversight, manages and oversees Claims Delegation Audits, including health plan and governing agency audits such as DMHC, CMS, and DHCS. The role develops and executes departmental strategies and the overall audit program, optimizes audit processes, and identifies ways to use technology and data to improve claims quality and reduce process costs. The position contributes to the Claims Delegation Oversight roadmap to ensure claims administration follows regulatory and internal guidelines for claims processing and adjudication, working with the Manager and Department Director. The role leads external audit planning and execution, oversees audit lifecycles, tracks and communicates results, coordinates supporting reports and documentation, conducts pre-audits, and manages root-cause analysis, remediation, and corrective action plans. It also reviews audit-related documentation and procedures, promotes adherence to legislative, regulatory, and contractual requirements, and oversees team training plans and effectiveness. The Supervisor collaborates across Claims and other departments, as well as with IT, Data Analytics, Internal Audit, Configuration, and Claims Operations, to resolve issues, improve systems and workflows, support testing and audit strategies, and carry out strategic initiatives and special projects. The position sets team goals, monitors performance, and recruits, develops, motivates, and leads team members.

Requirements

Solid understanding of DHCS and CMS rules and regulations governing claims adjudication practices and procedures.
Detailed knowledge of Medi-Cal, Medicare, and Medicaid program guidelines.
Ability to analyze and process all levels of claims accurately, using advanced knowledge of CMS and DMHC regulations.
Advanced reasoning, problem-solving, and planning skills.
Ability to multitask, prioritize, and work in a fast-paced environment under minimal supervision.
Proficiency in Excel, including creating and revising spreadsheets for accurate, clear reporting.
Bachelor of Science, Bachelor of Arts, or equivalent education and experience.
At least 3 years of claims administration experience in a Health Plan, IPA, or MSO setting.
At least 3 years of experience with health plan audits, delegation audit functions, and oversight.
Proven success improving key performance metrics through process improvement, cost reduction, and increased efficiency.
Demonstrated leadership skills, including coaching, mentoring, and fostering a culture of achievement.
Strong independent decision-making, influencing, and analytical skills.
Extensive knowledge of claims processing guidelines, including prospective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelines.

Nice To Haves

At least 2 years of people leadership experience.
Experience with EzCap, IDX, Cotiviti, or Burgess.
Experience working with clearinghouses such as Office Ally.
Experience managing offshore vendors.
Core system implementation experience.
Core system configuration experience.

Responsibilities

Develop and implement the operational strategy for planning, readiness, execution, and delivery of external audits, including corrective action plan management and improving audit scores.
Lead, monitor, and oversee the end-to-end lifecycle of external audits, including health plan, DMHC, and CMS audits.
Create, monitor, and manage metrics and goals for successful external audit execution and management.
Track, trend, report, and communicate audit results in a timely and effective manner.
Collaborate with the reporting team to ensure universe listings are delivered accurately and on time.
Ensure supporting documents are pulled on time and thoroughly reviewed before delivery.
Ensure pre-audits are conducted for external audits to assess readiness and conformity with internal health plan and regulatory requirements.
Lead root-cause analysis of deficiencies and develop and implement remediation and process-improvement solutions.
Collaborate with Claims Operations to remediate pre-audit issues and develop root-cause and prevention strategies.
Manage corrective action plans for audit findings, including root-cause analysis and prevention plans.
Ensure scheduled and ad-hoc health plan reports are pulled on time and review and approve their accuracy.
Review and approve cross-functional and departmental external audit documentation, workflows, policies, procedures, job aids, and standard operating procedures.
Promote adherence to internal processes for creating and maintaining claims processes, workflows, policies, procedures, job aids, and standard operating procedures.
Ensure adherence to legislative, regulatory, and contractual requirements.
Review and oversee the team’s training plan and strategy, measure training effectiveness, and develop remediation strategies.
Identify team training needs and gaps and ensure timely, effective training.
Build and maintain collaborative relationships with department leads to enable timely identification and resolution of problems and improvements.
Collaborate with Claims Operations and Internal Audit to develop external audit strategies, root-cause analyses, and prevention plans for claim-related issues.
Work with IT and Data Analytics to develop tools and maintain, update, or revise scorecards, dashboards, and reports.
Collaborate with Configuration and IT to improve system configurations and rules for accurate claims adjudication.
Recommend changes to system design, rules, and workflows affecting claims processing.
Contribute to Claims testing and audit strategy development and provide feedback based on day-to-day findings.
Conduct special projects, including business analyses, strategic planning, and implementation for new acquisitions and changing business or organizational requirements.
Develop and execute strategic initiatives and programs to enhance existing functions and develop new processes in support of corporate initiatives and requirements.
Develop team goals and objectives and implement strategies to achieve business outcomes.
Monitor team performance metrics against goals and coach and guide the team toward success.
Recruit, develop, motivate, and lead the team to improve operational performance.
Perform other duties as assigned.