The Claims Resolution Supervisor is responsible for providing structure and supervision for the departments' daily operations and functions. The supervisor works to meet or exceed department productivity and quality standards by coordinating staffing, balancing workloads, developing and implementing policy, procedure, and efficient workflows. The primary function of this role is to supervise staff in root cause resolution of escalated provider claim issues and impact analysis of the issue. The leader of this team is responsible for owning the claims resolution process including the intake and documentation of inquiries, projects, and closing the loop with relevant internal and external customers. The supervisor insures that the analyst collaborates closely with peers and management to ensure that root cause issues are analyzed, tracked, trended, and reported to all impacted areas for quick resolution. Proficient in facilitation and interpersonal communication, the supervisor also consistently demonstrates skills in organization, prioritization, professionalism, and coaching others.
Oversee the claims resolution process
Coordinate and communicate continuously with other departments to share information, best practices, systems issues, process solutions, and training needs
Proactively review and provide data analysis (root cause and trending issues) and financial impact assessment related to claims issues.
Ensure compliance with company and departmental policies and procedures
Establish and review internal controls to ensure goals, objectives, standards, and benchmarks for the department are met or exceeded
Strategizes resolution on highly sensitive matters in partnership with appropriate business partners to help mitigate reputational risk;
Works with business partners to handle difficult customer issues and to resolve complex situations urgently and with a high degree of professionalism.
Maintain working knowledge of workflow, systems, and tools used in the department
Maintains working knowledge of claims and configuration policies and procedures and trains associates on the same.
Works directly with claims, configuration, provider relations, and customer service to review and resolve complex issues related to provider/member claims.
Leads team to leverage insights to identify root causes of and trends in internal and external claims issues and shares those with functional business partners so they can take action to prevent future complaints, where possible.
Provides weekly, monthly, yearly, and ad hoc reporting to leaders and business partners.
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form.
Ability to deal with problems involving several concrete variables in standardized situations and manage sensitive issues with tact, diplomacy and good judgment on the telephone, in correspondence and in person.
Triages work to Configuration Support Analyst
Collaborate with and maintain open communication with all departments within CHRISTUS Health to ensure effective and efficient workflow and facilitate completion of tasks/goals
Screen, interview, and hire new employees
Training and development of new associates
Monitoring associate schedules - Review, correct, and approve employees' hours in a timely manner (Kronos time tracking)
Mentoring associates for career development: regular 1/1 rounding sessions, goal setting and routine assessments
Evaluate associate performance and recommend appropriate merit increases and promotions
Counsel associates regarding disciplinary and performance issues
Lead in the creation and maintenance of a positive working environment
Review employee engagement results and facilitate the development of action plans
Follow the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)
All other duties assigned by management
Excellent analytical skills
Exercises proper judgment and decision making to analyze the root cause of claims issues and resolve problems timely and accurately.
Ability to organize and prioritize work to meet deadlines
Strong computer application skills including, but not limited to, Microsoft Word, Excel, PowerPoint, and Visio
Excellent critical thinking skills
Ability to communicate effectively both verbally and in writing
Ability to exercise a high degree of independent judgment and discretion with respect to matters of significant importance.
Ability to handle and resolve complex issues independently
Knowledge of Medicare Advantage, Tricare and Health Care Exchange programs preferred
Knowledge of claims processing, system configuration, claim edits, provider data load, and adjustment adjudication preferred.
Knowledge of CPT/HCPCS, ICD10 coding and medical terminology.
Ability to learn new policies and processes based on written material and observation
Ability to establish and maintain professional, positive and effective work relationships
Bachelor's degree in related field or 5-7 years Managed Health Care experience required
Prior management experience required, 2-5 years highly desired.
Managed Care Claims processing experience preferred
Provider Data Management experience preferred
Claim system configuration experience a plus
Prior experience working with TRICARE, Health Care Exchange, and Medicare Advantage highly desirable.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.