The purpose of this position is to supervise the Fitness Claims Analysts, Fitness Claims Examiners and support staff and perform all aspects of system programming stages to ensure performance standards and client expectations are met.
· Supervises claims analyst, claims examiner and support staff activities.
· Monitors daily work for each Fitness Claims Analyst in first in, first out order to ensure analyst deadlines is met.
· Trains and /or coordinates training of new claim analyst staff on department processes as necessary.
· Answers analyst questions and offers guidance to Claims Analysts as needed.
· Triages analyst issues/questions from other departments related to day to day requests.
· Oversees the preparation for Health Plan, DMHC, CMS or other regulatory agency audits and ensures audit prep work is completed timely and accurately.
· Adjusts claims with special circumstances.
· Co-facilitates monthly claims meetings; prepares agenda and/or coordinates minutes for those meetings.
· Ensures examiner errors identified by the Claims Auditors or Claims Analysts are reported to the Claims Processing Supervisor.
· Assigns and monitors daily work for Fitness Claims Examiners to ensure processing deadlines are met.
· Trains and /or coordinates training of new ERP Claims Examiner staff on department processes as necessary.
· Answers processing questions and offers guidance to Claims Examiners as needed.
· Oversees and coordinates support staff workflow on a daily basis.
· Keeps Manager informed on issues of urgency, priorities, identified problems and provides feedback on work of subordinates.
· Documents subordinates’ performance, provides feedback, coaches, counsels, and disciplines.
· Participates in the hiring and termination process.
· Prepares and delivers performance evaluations.
· Assists Co-Supervisor with the various supervisor tasks/job duties as needed.
· Performs all aspects of system programming stages.
· Creates and submits programming requests to Manager for approval prior to submission to Operations Business Analyst team.
· Assists Manager with review of programming criteria submitted by Operations Business Analyst team.
· Review and approve programming criteria as needed to assist Manager during absences.
· Conducts, oversees and reports outcomes of user testing on all system programming including contract testing to Manager and/or Operations Business Analyst team.
· Monitors and updates the IHIS Programming Requests Tracking Spreadsheet for Fitness Claims and reports outcome to Leadership team.
· Prepares reports and assists with QI/QA as necessary
· Creates and/or monitors claims examiner production reports on a bi-monthly basis and reports results to Leadership team and payroll.
· Creates weekly KPI report and rotates task with supervisor team.
· Creates and updates Member Denial Letter templates for Commercial and Medicare Health Plans to assure compliance is met.
· Ensures quality review audits are performed as applicable for new examiner staff at 100% and seasoned staff at 2.6%.
· Review Fitness Claims reports received from Reports Team for accuracy as needed.
· Performs other duties and responsibilities as assigned.
· High School diploma or equivalent.
· Minimum 3 years experience in a managed care claims department, with at least 1 year as a claims examiner, and 1 year claims analyst / coordinator or claims auditor and 1 year claims supervisor preferred.
· 3 years computer experience including automated claims systems, word processing, excel spreadsheets, access databases and email.
· Familiarity with Managed Care, HMO, PPO health plan provisions.
· Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
· Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
· Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
· Ability to effectively organize, prioritize, multi-task and manage time.
· Demonstrated accuracy and productivity in a changing environment with constant interruptions.
· Demonstrated ability to analyze information, problems, issues, situations and procedures to develop effective solutions.
· Ability to exercise strict confidentiality in all matters.
Mobility: Primarily sedentary, able to sit for long periods of time.
Physical Requirements: Ability to speak, see and hear other personnel and/or objects. Ability to communicate both in oral and written form. Ability to travel within the facility. Capable of using a telephone and computer keyboard. Ability to lift up to 10 lbs.
Environmental Conditions: Usual office setting.