About this role
The Supervisor – Leads claims production team, ensuring accurate, timely, and compliant adjudication while developing staff, reducing errors and overpayments, and advancing organizational quality and financial goals. Monitor and review work of all Claims production staff to identify additional training needs and to ensure compliance with department quality and production standards. Provide performance feedback and identify developmental opportunities for Claims staff. Monitor and review claims production and transaction reports. Identify claims error trends and implement controls and changes that will minimize incorrect claims adjudication. Coordinate potential recovery efforts with Company Accounting and coordinate potential physician education opportunities with Company Physician Services. Work closely with other Company departments to ensure that all areas supporting claims meet appropriate claims quality goals. Ensure that all legal, regulatory, and policy requirements are met by keeping informed of changes and implementing necessary controls and/or programs to meet requirements. Manage and update claims production policies, workflows, and processes to ensure compliance with Claims department and State, Federal, and Health Plan quality standards. Provide analysis of claims quality adjudication results and identify training opportunities for the Claims team. In collaboration with the Claims QA and Training Specialist, Supervisor, ensure that Claims Representatives have a thorough understanding of Company claims adjudication policies and procedures. Coordinate provider contract, health plan benefit/DOFR, and system rules configuration testing with the Business Applications Configuration team. Ensure accurate reporting and timely submission of quarterly PDR timeliness reports. Prepare, coordinate, and facilitate external party PDR and adjustment audits. Develop any corrective action plans (CAPs) that result from PDR and adjustment audit findings, and monitor progress and application of documented CAPs. Work with Company departments on implementing controls to minimize claims overpayments and identify physician education opportunities with Network Management. Work closely with other Company departments and specifically the Claims QA and Training Specialist to communicate findings of recovery audits and to facilitate accurate adjudication of claims. Supervise direct reports by assigning and directing work; conducting employee evaluations, staff training, and development; taking appropriate disciplinary/corrective actions; and making hiring/termination recommendations. Mentor team members in both technical and functional areas to provide growth opportunities. Accountable for achieving departmental goals related to claims inventory, turnaround times, quality scores, production standards, and financial accuracy. Other duties as assigned.