Healthcare Talent is assisting our client in hiring a Supervisor, Claims (CQI) for their Claims Department.

The Claims Supervisor oversees the day-to-day operations of the Quality Analyst (QA) staff in the Continuous Quality Improvement (CQI) Unit of the Claims Department. This position is responsible for ensuring adherence to regulatory and internal guidelines in conjunction with company policies and procedures as they apply to claims processing and adjudication. 

Our client has a unique business philosophy; their goal is to provide employees with a place to excel – while really creating something meaningful in their work. This philosophy has helped them grow into an award-winning company. Employees are provided with room for advancement, competitive compensation, and an excellent benefit package.

Position Responsibilities

• Train, audit and supervise all QA staff to ensure adherence to the Medi-Cal and Medicare processing guidelines. Identify any new learning opportunities for staff (i.e. new desktops).

• Monitor staff to ensure department turn-around times for claims auditing are met. Ninety five percent (95% of all claims must be paid or denied within 30 calendar days and 100% within 60 days from date of receipt to date of financial run.

• Must serve as a back up to claims processing when needed to ensure the department turn-around times are met and maintain inventory within 21 days on hand.

• Responsible for prompt communication with staff. Must schedule monthly unit meetings to go over any changes to programs or training issues; schedule monthly one-on-one meetings with staff to go over their monthly progress regarding their success factors (production, quality, etc).

• Plan work for staff, assign daily claims and determine priorities of work done by staff.

• Set or recommend work performance standards.

• Review work procedures and recommend or change procedures to be more time/cost efficient.

• Assist with interviewing job applicants and make recommendations for hire as needed.

• Train, evaluate, and provide performance feedback to staff.

• Conduct employee counseling/corrective interviews with the assistance of Human Resources.

• Conduct claims presentations as assigned.

• Other projects and duties as assigned.

Required Skills

• Diffuse emotional situations with employees and/or provider representatives.

• Interact with peers face-to-face, over the phone and in writing in a manner that is professional and productive.

• Influence others using a positive approach.

• Provide clear, concise instruction to individuals of varying skill levels.

• Troubleshoot problem areas.

• Encourage and utilize suggestions and new ideas.

• Manage and keep track of multiple tasks.

• Remain objective when dealing with emotional topics or when having to give feedback to staff.

• Establish and maintain effective working relationships with all levels of staff, other programs, agencies, and the general public.

• Effectively utilize computer and appropriate software and interact as needed with company claims processing systems.

• Speak and write clearly and concisely.

• Encourage the professional performance and development of subordinate staff.

• Plan, organize and prioritize work.

Required Experience

Experience & Education

• High school diploma or equivalent is required; some college preferred.

• 3+ years of experience in a managed care environment that would have developed the knowledge and abilities listed.

• Substantial practical knowledge and understanding of relevant business practices and applicable regulations/policies.

• Previous experience in directing the work of others (i.e. training, responding to questions, etc.) and supervisory experience are preferred.

• Demonstrated ability to work closely and often with others.

Knowledge of:

• Principles and techniques of effective supervision.

• Technical area(s) of medical claims administration, including medical terminology, CPT, ICD-9 codes and HCPCS codes.

• Medi-Cal and Medicare program guidelines.

• Benefit interpretation and administration.

• Department reports, their purpose and how to interpret them.

• Department procedures, policies and expectations.

• Fundamental principles of writing and grammar, including proper report and correspondence format, correct spelling and proper word usage, grammar, punctuation, and sentence structure.

• Personal computers, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

If you feel that you have the skills we require, please respond to this posting with your contact information and your resume in a Word document. We look forward to hearing from you today!  

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