Job Description
Job Description
Description
Job Title : Supervisor – Claims Delegation Oversight
Department : Ops - Claims Ops
About the Role :
The Supervisor, Claims Delegation Oversight, is responsible for the management and oversight of all Claims Delegation Audits, including health plan and governing agencies audits, i.e., DMHC, CMS, and DHCS. This role will be responsible for the development and execution of department strategies, overall Audit program, Audit process optimization, and management, identifying and leveraging technology and data to improve the quality and minimizing process cost of Claims. The position alongside the leadership team will contribute to driving strategic planning, operational excellence, and accuracy of the claims process and ensure compliance with regulations and contract requirements for Medicare, Commercial Exchange, and Medicaid service lines. This position will contribute and influence overall Claims Delegation Oversight roadmap to ensure Claims Administrations are adhering to regulatory and internal guidelines as they apply to claims processing and adjudication. Working with Senior Manager and Department Director, Supervisor will collaborate with other Astrana Health departments and personnel to develop strategies to identify, mitigate and optimize operational and financial gaps.
What You'll Do
External Audit Planning, Execution & Support
- Develop and implement the operational strategy for driving all external audits for Prospect to ensure audit planning and readiness, successful audit execution and delivery, CAP management, and improve overall audit score
- Lead, monitor, and oversee the end-to-end lifecycle of all external audits, including but not limited to health plan audits, DMHC audits, CMS audits, etc
- Create, monitor, and manage metrics and goals for successful execution and management of all external audits
- Ensure Audit results are clearly tracked, trended, reported, and communicated timely and effectively
- Collaborate with the reporting team to ensure all universe listings are delivered timely and accurately
- Ensure all supporting documents are pulled timely and reviewed thoroughly prior to delivery
- Ensure a pre-audit is conducted for all external audits to gauge the health of an upcoming audit and to assure conformity with the internal health plan and regulatory guidelines and requirements
- Actively engage in Root Cause analysis of deficiencies, and lead efforts in the development and implementation of effective remediation and process improvement solutions.
- Collaborate with Claims operations to ensure any issues found as part of the pre-audit are readily remediated, including devising and implementation of root cause and prevention strategy
- Ensure corrective action plan (CAP) management for issues identified as part of all audits performed with clear root cause analysis and prevention plan
- Ensure all HP reports (scheduled and ad-hoc) are pulled timely and review / approve the accuracy of reports
Documentation, Training & Development
Review and approve cross- functional / departmental External Audit process documentation, workflows, policies, and procedures, job aides, and standard operating procedures for completeness and accuracyDrive and ensure internal process adherence for creating / maintaining cross- functional / departmental claims processes, workflows, policies, and procedures, job aides, and standard operating proceduresEnsure adherence to all Legislative, Regulatory, and Contractual requirementsReview, collaborate, and oversee the Training Plan & Training Strategy for the team, including measuring training effectiveness and remediation strategyIdentify training needs / gaps for the team and ensure timely and effective training is imparted to all team membersCollaboration
Build and maintain productive & collaborative intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting / Finance, Recovery, Compliance, Configuration, Network Management, IT Ops, etc.) to enable effective and timely problem / improvement identification & resolution and drive operational excellenceCollaborate with the Claims Operations and Internal Audit Teams to develop a robust external audit strategy, root cause analysis, and prevention plan for any claim-related issuesDrive and collaborate with the IT & Data Analytics team to create / develop tools to effectively maintain, update, or revise all scorecards, dashboards, and reports, as necessaryCollaborate with the Configuration and IT Teams to continuously improve upon system configuration / rules set up for accurate and effective claims adjudicationRecommend changes for system design, rules, and workflows affecting Claims processingProactively contribute to Claims testing / audit strategy development and provide timely feedback based on day-to-day findingsConduct special projects, including business analyses, strategic planning, and implementation efforts on new business acquisitions and changing business and organizational requirementsDevelop and execute strategic initiatives and programs to enhance existing functions and develop new processes in support of corporate initiatives and requirementsStaff Management
Develop goals and objectives for the team and rollout strategy to obtain the established business outcomeMonitor and track key performance metrics against established goals and coach / guide the team to achieve successRecruit, develop, motivate, and lead the team to continuously improve operational performanceQualifications
Solid understanding of the Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS) rules and regulations governing claims adjudication practices and procedures requiredDetail knowledge and understanding of Industry pricing methodologies, such as Resources-Based Relative Value Scale (RBRVS), Medicare / Medi-Cal fee schedule, All Patient Refined Diagnosis Related Groups (AP-DRG), Ambulatory Payment Classifications (APC), etcDetail knowledge of Medi-Cal, Medicare, and Medicaid program guidelinesPossess working knowledge of NCQA, DHS, and HCFA standardsKnowledge of medical terminology combined with detailed knowledge and experience with CPT, HCPCS, DRG, REV, OPS, ASC, ICD10, CRVS, RBRVS, CMS, ICE for Health Plan, DMHC and DHS fee schedules and CMS Medicare regulatory agencies, COB and Third-Party Liability recoveryAbility to coach and motivate employees to reach and sustain established performance standards and goalsAbility to direct the work of others and mediate interpersonal encounters with tact and diplomacy, complying with legal guidelines and company policyMust have hands-on claims auditing experience with a clear root cause and prevention plan managementMust have the ability to analyze and process all levels of claims accurately utilizing advanced level knowledge of CMS and DMHC RegulationsMust possess the ability to effectively present information and respond to questions from managers, employees, customersMust possess advanced reasoning and problem-solving abilities and planning skillsAbility to multi-task, prioritize and work in a fast-paced environment under minimal supervisionProficient in Excel including the ability to create and revise Excel spreadsheets to provide accurate and clear reportsBachelor of Science (BS) / Bachelor of Arts (BA) or equivalent education and experience required3+ years of claims administration experience in a Health Plan / IPA / MSO setting3+ years of experience with Health Plan Audits Delegation Audit functions and oversightProven success in improving key performance metrics, including process improvement, cost reduction, and improving efficiencyDemonstrated leadership skills, ability to coach, mentor, and foster a culture of achievementStrong independent decision-making, influencing, and analytical skillsExtensive knowledge of claims processing guidelines, including, perspective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelinesYou’re great for the role if :
2+ years of experience in people leadershipEzCap, IDX, Cotiviti Experience, Burgess ExperienceWorked with Clearinghouses like Office AllyExperience with managing offshore VendorsCore System implementation experienceCore System configuration experienceEnvironmental Job Requirements and Working Conditions
Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Dr. Monterey Park, CA 91754.The target pay range for this role is between $86,000.00 - $105,000.00. This salary range represents our national target range for this role.Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation.
Additional Information :
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
