Supervisor, Claims (CQI) Needed!

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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