Claims Supervisor - Provider Dispute Resolution

The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Claims Supervisor. The Provider Dispute Supervisor assists the claims manager with the daily oversight and management of the claims provider dispute process.  The supervisor will direct and support the day to day activities of assigned staff and monitor the accurate and timely resolution of disputes for all lines of business. 

The essential duties and responsibilities will include the following: 

• Accomplish staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching, counseling, and implementing corrective action steps when necessary; developing, coordinating, and enforcing systems, policies, procedures and productivity standards.  Complete performance evaluations in a timely manner.
• Plan, organize and direct work activity of the PDR Team consistent with organizational policies and procedures and which are compliant with State and Federal guidelines.
• Monitor and review PDR Specialist workload and productivity; make assignments and provide direction and backup as needed.
• Oversees research, investigation and resolution of all types of Provider Disputes. 
• Ensure projected/departmental goals are met; develop strategies and schedules for meeting stated goals.
• Respond to escalated or complex provider inquiries regarding Provider Disputes
• Assist manager to develop policies and procedures and/or desk procedures for the Team.
• Assist manager in the training of PDR staff including the development and review of related job aids.
• Continuously monitor and evaluate unit performance and take steps to improve efficiency and quality of unit operations.
• Implement necessary policy and regulatory changes.
• Communicate newly-identified and potential issues to Claim Manager or other departments as necessary
• Resolve second level PDRs
• Recommend opportunities for improvement identified through the trending and analysis of all incoming PDRs.
• Perform all duties of a PDR Specialist
• Manage auditing and quality control; log, track and report results to the Management Team.
• Maintain knowledge of industry trends, bet practices and regulatory requirements.
• Facilitate and document meetings
• Perform other duties as assigned

Requirements

Education and Experience: Minimum two (2) years processing health plan provider disputes. Previous experience working in a supervisory capacity. Experience with Medi-Cal and Medicare preferred. Bachelor’s degree in related field preferred.

Knowledge of: Managed Care. Provider billing rules. CPT, HCPCS, revenue and ICD-10 coding . State and federal regulation pertaining to the processing of provider disputes. Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.

Ability to: Work cooperatively with others. Work as part of a team and support team decisions. Communicate effectively, both verbally and in writing. Collaborate with multiple parties to solve problems and solve problems independently. Provide feedback in a constructive and growth-oriented manner. Adapt to changes in requirements/priorities for daily and specialized tasks.

Starting Compensation Range: - Depending on Experience

Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost.  Employee pays a small portion (5%) of the dependent premiums for medical and dental benefits.  Additional HPSM benefits include fully paid vision, life, AD&D, STD, and LTD insurance; retirement plan (10% of salary for compensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.