Claims Supervisor Job at Driscoll Health
Where compassion meets innovation and technology and our employees are family.
Thank you for your interest in joining our team! Please review the job information below.
ESSENTIAL DUTIES AND RESPONSIBILITIES -
Positions in this class may perform any or all of the below listed duties. These should be interpreted as examples of the work and are not necessarily all-inclusive
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Provide supervision for the Claim Administration team, including but not limited to claim support activities including paper claim OCR scanning/verification and administrative support, claims processing, coordination of benefits, other insurance investigation, claim appeals, claim adjustments, claim refunds, claim quality audit, root cause analysis, process improvement, and issue resolution.
Provide oversight of vendor relationships involving COB, Third Party Liability, and Subrogation.
Ensure claims are managed and adjudicated in adherence with all applicable Federal, State, Contract, Compliance and Regulatory requirements.
Ensure the appropriate training, processes, workflows, and automated systems are in place to ensure claims are processed timely, efficiently, and accurately.
Adjust staff assignments, direction, and priorities to quickly respond to changing priorities and business needs; ensure flexibility of the department through effective communication of business rationale, use of change management techniques and setting a positive attitude example.
Interface and collaborate with internal and external business partners to achieve resolution of claims issues and ensure highest levels of Provider satisfaction.
Actively engage in Root Cause analysis of deficiencies, and lead efforts in development and implementation of effective remediation and process improvement solutions.
Provide mentoring and coaching for Claims Administration staff in order to enhance understanding of departmental policies, procedures and workflows and to provide opportunities for professional development and departmental bench strength.
Provide leadership and oversight of claim cost containment efforts, including appropriate Contract, Benefit, and coding administration.
Monitor appropriate Texas Medicaid resources (CMS, HHSC, TMHP, etc.) to continually ensure health plan adherence with State and Federal Texas Medicaid and CHIP benefits.
Monitor and communicate performance goals and results to staff, engaging in appropriate coaching and development opportunities, and improvement action plans as needed.
Supervise the claim issue resolution process from identification to solution; ensure appropriate staff is assigned to resolve issues, ensure active collaboration with business partners as needed, and ensure issues of high risk are communicated and escalated appropriately.
Develop and maintain an environment that encourages teamwork and communication, and supports quality and process improvement suggestions and solutions.
Demonstrate business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
Perform other related work as requested.
SUPERVISORY RESPONSIBILITIES
Effectively administers performance management system including:
Developmental feedback
Goal setting
Assesses competency
Progressive discipline
Strong knowledge of and effective in administering health system policies and procedures. Responsible for sound management of human resources. Makes and implements decisions compatible with organizational goals. Maintains composure, effectiveness, and flexibility under pressure.
BEHAVIORAL EXPECTATIONS
Should apply and be listed on all job descriptions.
- Customer Service – Enthusiastically interacts with all customers. Assumes personal responsibility for meeting customer needs. Consistently demonstrates a commitment to customer satisfaction.
- Interpersonal Skills - Sensitive to the needs, ideas, and feelings of others. Develops and maintains rapport with others. Listens well. Facilitates a group process.
- Adaptability/flexibility – Demonstrates the ability to change behaviors and plans to meet rapidly changing/ competing job demands (new or unusual situations). Receives change as a challenge. Revises plans to meet changing circumstances. Maintains composure, effectiveness, and flexibility under pressure.
- Communication – Clearly and effectively communicates ideas and requests to others. Persuades or influences others through spoken or written communication.
- Initiative – Starts and completes tasks with minimum of prompting. Willing to make recommendations and assume additional responsibilities.
- Team Player – Fully participates in maintaining a positive team environment that is conducive to customer satisfaction. Builds trust among co-workers, focusing on accomplishing health system and departmental mission and goals.
- Organized and efficient – Organizes work and uses time efficiently. Recommends innovative ways of doing work more efficiently and effectively.
- Core Values –Practices DCH core values.
EDUCATION AND/OR EXPERIENCE -
Any combination of education and experience that would likely provide the required knowledge, skills, and abilities is qualifying.
- An Associate’s degree preferred, or equivalent experience.
- Minimum five years professional experience in claims analysis and Coordination of Benefits, including order of benefit determination and payment calculation; experience with Texas Medicaid preferred.
- Minimum one year Supervisor experience, Medicaid experience preferred.
KNOWLEDGE SKILLS AND ABILITIES
- Ability to work collaboratively to produce results across functional teams.
- Demonstrates ability to develop and execute action plans to meet goals and objectives.
- Demonstrates excellent written, oral, and electronic communication skills and effective time management.
- Strong understanding of technical and operational processes and methods to improve those processes, with a strong focus on achieving customer satisfaction and driving for results.
- Adaptability to quickly change priorities and focus based on business need.
- Ability to manage change and to obtain operational results with minimal disruptions through innovative and creative means.
- Ability to read, analyze, and interpret benefits, contracts, and governmental regulation, and to develop claims and technical procedural manuals.
- Excellent analytical and problem-solving skills to identify issues, errors, and determine cause; ability to make recommendations for quality improvement and/or change management.
- Proficient understanding of Coordination of Benefits and Order of Benefit Determination logic.
- Experience with claim auditing and quality improvement initiatives preferred.
ENGLISH LANGUAGE SKILLS
- Ability to write, read and interpret documents such as policies and procedures.
- Ability to write reports, business correspondence, and procedure manuals.
- Ability to effectively communicate information and respond to questions from leadership, peers, staff, customers, and the general public.
MATHEMATICAL SKILLS
- Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions and decimals.
- Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
- Ability to calculate figures and amounts such as discounts, interest, proportions, percentages, and aging.
REASONING ABILITY
- Ability to define problems, collect data, establish facts, and draw valid conclusions.
- Ability to interpret written and oral instructions and adapt based on variables and priorities.
- Ability to interpret business results and key performance indicators to translate into actionable work plans to address deficiencies.
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