Supervisor - Claims Delegation Oversight

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

Collaboration

Staff Management

Qualifications

You’re great for the role if :

Environmental Job Requirements and Working Conditions

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.

Astrana Health (NASDAQ : ASTH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient.

Our platform currently empowers over 20,000 physicians to provide care for over 1.7 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.