Supervisor, Claims BPO Operations

Who we are

Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.

Our commitment is to:

• Strive to apply an equity lens to all our work. 
• Reduce health disparities. 
• Create an equitable work environment. 

 

About the Role

This position is responsible for supervision and leadership for BPO Operations including direct management of staff, cross-departmental coordination and vendor relationship management. Supports the interface between Community Health Plan of Washington (CHPW) and vendors (third party administrators) for claims benefit system configuration and third-party administration (TPA). Manages business requirement development, configuration, user testing, workflow, quality assurance, production support, escalated claims/provider issues, encounter data, new product implementation, electronic data files, fee schedules/rates, provider contract templates and third-party administration for claims and billing. Project management, develop and execute process improvement, root cause analysis and remediation.

To be successful in this role, you will have:

• Bachelor’s degree in health care or an equivalent combination of education and highly equivalent experience required.
• Minimum five (5) years’ managed care/health plan operations experience required.
• Minimum four (4) years’ leadership (supervisory/management) experience in a related field, required.
• Minimum three (3) years’ experience as a Senior Operations Analyst at CHPW, preferred.
• Experience overseeing healthcare claims operations, including benefits administration, system configuration, and implementation of complex provider rates, pricing methodologies, fee schedules, clearing house administration.
• Proven leadership in managing professional and institutional claims within third‑party administration environments, ensuring accuracy, compliance, and operational excellence.
• Background in Medicaid, Medicare, OIC claims administration, benefit interpretation predilection for process improvement, identifying, planning and executing appropriate strategies, methodologies and activities to achieve team and company goals.

Essential functions and Roles and Responsibilities:

• Responsible for the direct supervision of Operations staff, including interviewing, hiring, performance management, time keeping records, training, coaching and employee development. Building a cohesive, empowered and productive work environment. Responsible for improving production processes and quality on a continuous basis.
• Manage prioritization of system configuration, testing and implementation activities involving claims and encounter data. Facilitate the development and execution of user acceptance scenarios and scripts for testing system changes and enhancements.
• Manage claims and billing Clearinghouse (TPA) for Medicaid programs.
  • Oversee end‑to‑end claims and billing operations with the TPA for Medicaid programs, ensuring accuracy, efficiency, and alignment with program requirements.
  • Provide strategic guidance to providers on claims preparation and submission, including developing training materials and enabling process improvements.
  • Ensure timely and compliant submission of all required program documentation, maintaining strong operational controls.
  • Lead oversight of clearinghouse claim workflows, including escalation management, technical issue resolution, and root‑cause analysis for provider rejections.
  • Drive program compliance and performance through rigorous monitoring, reporting, and continuous improvement initiatives.

• Regularly monitor departmental contractual compliance with state, CMS, OIC requirements (claims benefit configuration, claims timeliness, claim denials, encounter data submissions, clearing house); including supporting the collection and submission of required operational performance metrics and data reporting requirements. Provide oversight including SLA reporting and audit to Operations’ assigned vendors.
• Lead the analysis and documentation of business process workflows, policies and procedures for Operations. Act as the subject matter expert for Operations in companywide or specific projects, including configuration on vendor systems.
• Monitor the performance of processes within the Operations Department identifying improvement strategies and interventions when targets a