Claims Adjustment Supervisor

The role of the Claims Adjustment Supervisor is to oversee and manage the day to day operations of the Claims Adjuster and Senior Claims Adjuster teams. Ensures that all adjustment requests are processed timely and accurately. The Claims Adjustment Supervisor is responsible for inventory management, appropriate work assignment and review/processing of high dollar claims. This position serves as the primary point of contact for their direct reports in resolving claim questions, quality disputes, training, mentoring/coaching. This role interacts heavily with the Provider Relations, Contracting and Provider Services teams. Supports our high profile providers, providing exceptional customer service to those groups.

The Claims Adjustment Supervisor provides support to the Manager of Claims Production, and as needed, fills the role of a claims department subject matter expert (SME) on committees and projects.

Duties and Responsibilities:

Responsibilities include, but are not limited to the following:

• Oversees day-to-day activities of adjustment teams, including managing staffing levels, inventories and workflows based on staffing resources and team priorities.
• Represents Neighborhood to internal and external customers in a professional manner.
• Responsible for managing inventory reports.
• Ensures that policies and procedures are followed by all Claims Adjustment staff.
• Establishes productivity and quality measurements using available data.
• Work collaboratively with leaders and team members to set training and quality assurance plans for new hires.
• Helps to forecast staffing needs based inventory trends, claim types, new products/benefits, etc.
• Manages employee performance, including monthly 1:1s, mid-year and annual reviews. Hold regular team meetings.
• Documents and delivers Performance Improvement Plans to employees not meeting expectations.
• Works in collaboration with appropriate teams to ensure root-cause analysis is clear for all claim trends.
• Supports user acceptance testing and post implementation QC of new functions, features, system upgrades and new implementations.
• Ensures the satisfactory resolution of operational issues with the provider community.
• Evaluates candidates during the interview process to make hiring determinations.
• Trains new staff and/or staff moving into new positions within the department. Conducts on-going cross-training of existing staff.
• Provides support and guidance to all teams within the department.
• Monitors and oversees escalated issues are resolved within the abbreviated turnaround times.
• Partners with the Documentation Specialist to update/create desk top procedures for staff acting as a subject matter expert (SME).
• Oversees any offshore activity related to scanning and/or claims adjustment processing.
• Provides functional expertise to all staff responsible for any aspect of claims adjustment and processing.
• Trends adjustment root causes and work towards process or systemic fixes.
• Identifies new and improved methods to research, report, analyze and resolve claim processing inaccuracies and/or processes used in department.
• Works with the Manager and Director to recommend process improvements, develop or modify policies and procedures to enhance teams and NHPRI performance.
• Other duties as assigned.
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.

Qualifications:

Required:

• Associates degree or sufficient work experience and background to equate to the degree
• Three (3) or more years of claims experience in health-care environment
• Prior supervisory experience or a demonstrated ability for a leadership position for an internal candidate
• Proficient knowledge of healthcare data systems and managed care principles
• Proficient understanding and experience in all aspects of claims adjudication, processing, and analysis
• Proficient knowledge of industry standard billing practices
• Demonstrated experience in provider and facility reimbursement methodologies for Medicaid, Medicare, and Commercial plan
• Proficient knowledge of COB, TPL and Workers Compensation regulations and the order of benefit rules
• Strong PC abilities in Outlook, and Microsoft suite such as Word, PowerPoint, and Excel
• Strong process orientation and analytical capabilities, with demonstrated ability to implement change
• Exceptional organizational and troubleshooting skills
• Ability to coach teams to meet and maintain departmental metrics and deadlines
• Excellent Customer service skills
• Exceptional verbal and written communications skills
• Ability to manage multiple projects simultaneously
• Ability to understand business systems and articulate deficiencies and opportunities

Preferred:

• Bachelors Degree
• Coding certificate from the American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA)
• Knowledge of Optum Encoder, similar coding software or website

Core Company-Wide Competencies:

• Communicate Effectively
• Respect Others & Value Diversity
• Analyze Issues & Solve Problems
• Drive for Customer Success
• Manage Performance, Productivity & Results
• Develop Flexibility & Achieve Change

Job Specific Competencies:

• Collaborate & Foster Teamwork
• Attend to Detail & Improve Quality
• Exercise Sound Judgement & Decision Making

FDR Oversight:

• Business Lead Level:

In the role of business lead for assigned FDR; incumbent is responsible to complete comprehensive oversight and monitoring of their vendor that incorporates the following elements: efficient and effective operations; compliance with laws, regulations, policies, procedures; and other company performance issues designed to reduce risk and add value to the company.

Flexible Work Arrangement:

• Yes

Telecommuting Arrangement:

• Yes, ad-hoc

Travel Expectations:

• Some travel locally between locations is required

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.