Supervisor - Claims Quality Assurance (Accountable Care)

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Day - 08 Hour (United States of America)

This is a Stanford Health Care job.

A Brief Overview
This position is responsible and accountable for the supervision and performance management of Claims Auditor/Trainers and Claims Examiner III's, as well as overseeing day to day operations of the Claims Quality Assurance team. Responsible and accountable for ensuring Claims department compliance with Stanford Medicine Partners (SMP) claims processing policies. Ensures overall claims adjudication is in accordance with State, Federal and Health plan regulatory requirements and guidelines. Develop training programs for Claims Examiners.

Provide organization and a unified structure to the claims transaction review process. Responsible for identifying claims transaction inconsistencies, as well as implementation of controls and changes to systems and policies that support claims adjudication, thereby minimizing incorrect claims payment.

Locations
Stanford Health Care

What you will do

• Staff Supervision

• Supervises subordinate personnel including: hiring, determining workload and delegating assignments, training, monitoring and evaluating performance, and initiating corrective and/or disciplinary actions.

• Responsible for ensuring staff compliance with corporate and departmental policies and procedures.

• Provides first level input for developmental goals and evaluations for Claims Auditors/Trainers and Claim Examiner III’s, to include drafts of employee evaluations.

• Plan, organize and direct overall workplace functions; coordinate time, vacation schedules and staff coverage; establish departmental procedures.

• Monitor and review quality and audit reports to identify additional training needs and to ensure compliance with Claims department quality standards.

• Administration & Personnel

• Responsible for developing and administering measurement devices, including tests and post training evaluations to determine the level of trainee performance and training effectiveness achieved. Serve as the primary point of contact to answer questions related to various claim issues and resolve non-routine, complex claim/benefit adjudication issues for department staff as well as other internal customers.

• Work closely with other SMP departments to ensure that all areas supporting claims meet appropriate claims quality goals.

• Compliance

• Reviews operational reports to ensure compliance with State, Federal and Health plan regulatory requirements.

• Ensures that all legal, regulatory and policy requirements are met by keeping informed of changes and by implementing necessary controls and/or programs to meet requirements.

• Exhibits a thorough understanding of industry standard claims processing guidelines.

• In collaboration with the Claims Supervisor, responsible for ensuring that Claims Examiners have a thorough understanding of SMP claims adjudication policies and procedures.

• Facilitate Health plan claims audits as well assist with other external audits, e.g., annual financial audits. Develop corrective action plans that address negative audit findings.

• Preparation and timely submission of timeliness and regulatory reports.

• Collaboration & Communication

• Collaborates and effectively interfaces with all departments and employee levels to ensure optimal results and productive working relationships.

• Responsible for the identification and resolution of provider claim issues including support of Network Management and Customer Service staff in communications back to providers.

• Work with the Recovery department on implementing controls to minimize overpayment and identify physician education opportunities with Network Management.

• All other duties as assigned including department-specific functions and responsibilities

• Performs other duties as assigned and participates in organization projects as assigned.

• Adheres to safety, P4P’s (if applicable), HIPAA and compliance policies.

Education Qualifications

• High school graduate

Experience Qualifications

• Seven (7) years prior claims processing and auditing experience in an IPA or HMO related setting with a minimum of two (2) years in a supervisory capacity

• Working understanding