About this role
Job Title: Supervisor – Claims Delegation Oversight Department: Ops - Claims Ops
About the Role
The Supervisor, Claims Delegation Oversight, is responsible for the management and oversight of all Claims Delegation Audits, including health plan and governing agencies audits, i.e., DMHC, CMS, and DHCS. This role will be responsible for the development and execution of department strategies, overall Audit program, Audit process optimization, and management, identifying and leveraging technology and data to improve the quality and minimizing process cost of Claims. This position will contribute and influence overall Claims Delegation Oversight roadmap to ensure Claims Administrations are adhering to regulatory and internal guidelines as they apply to claims processing and adjudication.
Working with Manager and Department Director. External Audit planning, execution & support Develop and implement the operational strategy for driving all external audits for Astrana Health to ensure audit planning and readiness, successful audit execution and delivery, CAP management, and improve overall audit score Lead, monitor, and oversee the end-to-end lifecycle of all external audits, including but not limited to health plan audits, DMHC audits, CMS audits, etc Create, monitor, and manage metrics and goals for successful execution and management of all external audits Ensure Audit results are clearly tracked, trended, reported, and communicated timely and effectively Collaborate with the reporting team to ensure all universe listings are delivered timely and accurately Ensure all supporting documents are pulled timely and reviewed thoroughly prior to delivery Ensure a pre-audit is conducted for all external audits to gauge the health of an upcoming audit and to assure conformity with the internal health plan and regulatory guidelines and requirements Actively engage in Root Cause analysis of deficiencies, and lead efforts in the development and implementation of effective remediation and process improvement solutions.
- Collaborate with Claims operations to ensure any issues found as part of the pre-audit are readily remediated, including devising and implementation of root cause and prevention strategy Ensure corrective action plan (CAP) management for issues identified as part of all audits performed with clear root cause analysis and prevention plan Ensure all HP reports (scheduled and ad-hoc) are pulled timely and review/approve the accuracy of reports Documentation, Training & Development Review and approve cross-functional/departmental External Audit process documentation, workflows, policies, and procedures, job aides, and standard operating procedures for completeness and accuracy Drive and ensure internal process adherence for creating/ maintaining cross-functional/departmental claims processes, workflows, policies, and procedures, job aides, and standard operating procedures Ensure adherence to all Legislative, Regulatory, and Contractual requirements Review, collaborate, and oversee the Training Plan & Training Strategy for the team, including measuring training effectiveness and remediation strategy Identify training needs/ gaps for the team and ensure timely and effective training is imparted to all team members Collaboration Build and maintain productive & collaborative intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting/ Finance, Recovery, Compliance, Configuration, Network Management, IT Ops, etc.) to enable effective and timely problem/improvement identification & resolution and drive operational excellence Collaborate with the Claims Operations and Internal Audit Teams to develop a robust external audit strategy, root cause analysis, and prevention plan for any claim-related issues Drive and collaborate with the IT & Data Analytics team to create/ develop tools to effectively maintain, update, or revise all scorecards, dashboards, and reports, as necessary Collaborate with the Configuration and IT Teams to continuously improve upon system configuration/ rules set up for accurate and effective claims adjudication Recommend changes for system design, rules, and workflows affecting Claims processing Proactively contribute to Claims testing/ audit strategy development and provide timely feedback based on day-to-day findings Conduct special projects, including business analyses, strategic planning, and implementation efforts on new business acquisitions and changing business and organizational requirements Develop and execute strategic initiatives and programs to enhance existing functions and develop new processes in support of corporate initiatives and requirements Staff Management Develop goals and objectives for the team and rollout strategy to obtain the established business outcome Monitor and track key performance metrics against established goals and coach/ guide the team to achieve success Recruit, develop, motivate, and lead the team to continuously improve operational performance Other duties as assigned