Claims Supervisor jobs in San Diego, CA

Description

POSITION SUMMARY

Responsible for Claims Department and Provider Services Department compliance with all Medicare and Medi-Cal regulatory requirements. Leads weekly and monthly compliance audits, including (but not limited to): acknowledgement, adjudication turnaround time, lag, inventory, fraud, waste and abuse, accuracy, interest payments, data sweeps, and provider disputes process.

COMPLIANCE WITH REGULATIONS

Works closely with all departments necessary to ensure that the processes, programs and services for all lines of business are accomplished in a timely and efficient manner in accordance with CHG policies and procedures, contractual provisions, and compliance with applicable state and federal regulations.

RESPONSIBILITIES

• Leads weekly and monthly compliance audits in the following claims processing areas: claims acknowledgement, adjudication turnaround time, lag, pending inventory, provider unbundling patterns, interest payments, handling of misdirected claims, completion of data sweeps, and other focused audits.

• Leads weekly and monthly compliance audits for the following provider dispute processing areas: acknowledgment requirements, accuracy, interest payments, inventory control, routes to other departments, and other focused audits.

• Supervises the daily activities and performance of the Provider Services and Audit teams. May be required to supervise different activities/projects, as need arises.

• Provides written reports and analysis on claims audit activities, including identification of areas requiring improvement to meet or exceed regulatory requirements.

• Works closely with other departments to ensure that routed claims are processed and returned to the Claims and Provider Services Departments in a timely and consistent manner.

• Assists in the analysis and interpretation of claims and provider disputes compliance requirements and provides recommendations for implementation.

• Works closely with Compliance Department on Fraud, Waste, and Abuse activities, including quarterly analysis of trends identified through Virtual Examiner (unbundling) software.

• Participates in all Claims Department and Provider Disputes compliance audits, such as Medicare Finance audit, DMHC claims audit, CMS data validation audit, etc.
   

Qualifications

EDUCATION

• Bachelor’s Degree in Business or related field.

EXPERIENCE/ SKILLS

• Advanced knowledge of Excel and Word.

• Knowledge of HMO operations preferred.

• Strong knowledge of Medicare and Medi-Cal claims and provider disputes compliance requirements.

• A minimum of four years of supervisory experience, preferably in a Claims Department.

• Excellent analytical and planning skills; organizational and prioritization skills.

• Ability to work in a fast-paced and heavy volume environment

 
PHYSICAL REQUIREMENTS

• Prolonged sitting, infrequent moderate lifting, bending and stooping.

• May be required to work evenings and/or weekends. 

**Must have current authorization to work in the USA**

Community Health Group is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and trainings. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action .