Job description

This is a Stanford Health Care - University Healthcare Alliance job.

A Brief Overview
This position is responsible and accountable for the supervision and performance management of Claims Supervisor and Claims Examiner II's, as well as overseeing day to day operations of the Claims department. Responsible and accountable for ensuring Claims department compliance with University Healthcare Alliance claims processing policies. Ensures overall claims adjudication is in accordance with State, Federal and Health plan regulatory requirements and guidelines. Provide organization and a unified structure to the claims inventory management 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. Provide management and oversight of external vendors.

Locations
Stanford Health Care - University Healthcare Alliance

What you will do

• Staff Supervision (1, 2, 3, 4)

a. Supervises subordinate personnel including: hiring, determining workload and delegating assignments, training, monitoring and evaluating performance, and initiating corrective and/or disciplinary actions.
b. Responsible for ensuring staff compliance with corporate and departmental policies and procedures.
c. Provides first level input for developmental goals and evaluations for Claims Supervisor and Claim Examiner II’s, to include drafts of employee evaluations.
d. Plan, organize and direct overall workplace functions; coordinate time, vacation schedules and staff coverage; establish departmental procedures.
e. Monitor and review quality and audit reports to identify additional training needs and to ensure compliance with Claims department quality and production standards.

• Administration & Personnel (1, 2, 3, 4)

a. 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.
b. Work closely with other University Healthcare Alliance departments to ensure that all areas supporting claims meet appropriate claims performance goals.

• Compliance (1, 2, 3, 4)

a. Reviews operational reports to ensure compliance with State, Federal and Health plan regulatory requirements.
b. 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.
c. Exhibits a thorough understanding of industry standard claims processing guidelines.
d. In collaboration with the Claims Quality Assurance Manager, responsible for ensuring that Claims Examiners have a thorough understanding of University Healthcare Alliance claims adjudication policies and procedures.
e. Assist with claim audits.

• Collaboration & Communication (1, 2, 3, 4)

a. Collaborates and effectively interfaces with all departments and employee levels to ensure optimal results and productive working relationships.
b. Responsible for the identification and resolution of provider claim issues including support of Network Management and Customer Service staff in communications back to providers.
c. Work with business departments to ensure consistent compliance with internal claims service level agreements.

• All other duties as assigned including department-specific functions and responsibilities (1, 2):

a. Performs other duties as assigned and participates in organization projects as assigned.
b. Adheres to safety, P4P’s (if applicable), HIPAA and compliance policies.

Education Qualifications

• Bachelor’s degree or equivalent education and experience.

Experience Qualifications

• Ten (10) years prior claims processing experience in an IPA or HMO related setting with a minimum of five (5) years in a supervisory capacity.
• Working understanding of basic computer operations and medical insurance rules/regulations.
• Thorough knowledge of medical terminology, claim processing procedures/systems, auditing, and a thorough understanding of claim protocols, industry standards and CMS regulations as it relates to claims payment and compliance. Advanced knowledge of claims processing systems architecture, which will facilitate troubleshooting of claims transaction related issues.
• Basic understanding of Microsoft Word and Excel applications.
• Advanced knowledge of and working experience with ICD-9, CPT and HCPC coding systems.

Required Knowledge, Skills and Abilities

• Supervise others by assigning/directing work; conducting employee evaluations, staff training and development, taking appropriate disciplinary/corrective actions and making hiring/termination recommendations.
• Effective oral and written communication skills.
• Able to assess and coordinate departmental workflows effectively.
• Ability to train using instructional material. Ability to write procedural updates and clarifications of policies.
• Relies on extensive experience and judgment to plan and accomplish goals.
• A wide degree of creativity and latitude is expected.
• Ability to work independently, and organize and prioritize work.
• Independent decision making skills and demonstrated ability to take initiative to resolve issues.

Licenses and Certifications

• None

Job Type: Full-time

Pay: $124,800.00 - $162,780.00 per year

Benefits:

• 401(k)
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Physical setting:

• Office

Schedule:

• Monday to Friday

Supplemental pay types:

• Bonus pay

Work Location: Hybrid remote in Newark, CA 94560

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