Supervisor, Provider Claims Resolution & Recovery - Claims

What you can expect! 

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

The Supervisor, Provider Claims Resolution & Recovery - Claims monitors daily activity of assigned inventories, including disputes, appeals, adjustments, special projects, and outgoing correspondence. Reviews special projects and delegate to appropriate units for processing. Supervises Claims Appeals Resolution team members including questions, productivity, quality, attendance, and performance evaluations. Establishes and delegates work assignments according to team member job specifications and business needs. Assists with handling escalated phone calls, adjustments, disputes, appeals, or training needs as required. Identifies trends in dispute and or payment issues and facilitate internal awareness to initiate a coordinated effort across claims units for education and improvement of accuracy. Communicates with Providers regarding claims payment inquiries, disputes, or appeals. Generates daily/periodic inventory control reports, regulatory reporting compliance. Coordinate with other IEHP departments to facilitate resolution of claim-related issues. Identify and report claim-related billing issues to various departments for follow-up provider education. Regulatory audit preparation and research complex claims as needed.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary.
• CalPERS retirement.
• State of the art fitness center on-site.
• Medical Insurance with Dental and Vision.
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development.
• Wellness programs that promote a healthy work-life balance.
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

1. Monitors daily activity of assigned inventories, including disputes, appeals, adjustments, special projects, and outgoing correspondence.
2. Review special projects and delegate to appropriate units for processing.
3. Supervises Claims Appeals Resolution team members including questions, productivity, quality, attendance, and performance evaluations.
4. Establish and delegate work assignments according to team member job specifications and business needs.
5. Assists with handling escalated phone calls, adjustments, disputes, appeals, or training needs as required.
6. Recognize trends in dispute and or payment issues and facilitate internal awareness to initiate a coordinated effort across claims units for education and improvement of accuracy.
7. Communicate with Providers regarding claims payment inquiries, disputes, or appeals.
8. Generate daily/periodic inventory control reports, regulatory reporting compliance.
9. Serves as liaison between IEHP and its delegated entities for provider claim appeals received.
10. Coordinate with other IEHP departments to facilitate resolution of claim-related issues.
11. Identify and report claim-related billing issues to various departments for follow-up provider education.
12. Assist with audit preparation and research complex claims as needed.
13. Attend key strategic meetings that are necessary to maintain a viable knowledge base within the team.

Education & Requirements 

• Four (4) years of experience in a Managed Care environment in the areas of claims processing, and or provider payment appeals and disputes, with at least one (1) year in a supervisory capacity.
• High School Diploma or GED required.

Key Qualifications

• Must have a valid California Driver's License.
• Extensive knowledge of ICD9, CPT and Revenue Codes. Knowledgeable in CMS, DHMC and DHCS regulatory guidelines, including AB1455. Principles and techniques of supervision and training. A thorough understanding of claims industry and customer service standards.
• Strong analytical and problem-solving skills. Microsoft Office, Advanced Microsoft Excel. Analytical skills with emphasis on time management, database maintenance, spreadsheet manipulation, and problem solving. Strong writing, organizational, project management proficiency required. Must have excellent interpersonal and communication skills.
• Medi-Cal program and benefit requirements experience desired. HMO or Managed Experience preferably in an HMO or Managed Care setting. Medicare and/or Medi-Cal experience preferred. Prior experience in a lead role or customer service environment is a plus.

Start your journey towards a thriving future with IEHP and apply TODAY!

This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA)