Supervisor, Claims Processing - Covered California

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, Claims Processing – Covered California provides daily oversight of claims staff, business processes and inventory management. This role ensures that the claims team follows state/federal regulations and standard operating procedures. The Claims Processing Supervisor – Covered California develops best practices to optimize claim processing quality. This person also evaluates professional skills of team members and provides appropriate work assignments, as well as resolve claim payment issues and quality oversight.

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
• Telecommute schedule
• 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. Oversee timely and accurate processing of claims. Support issue resolution and escalated cases. Identify claim trends and initiate corrective actions.
2. Ensure compliance with federal/state regulations and Covered California requirements. Monitor for audit readiness and support compliance-related activities. Participate in regulatory audits and implement updates as required.
3. Work with the Quality Assurance (QA) team to identify gaps and implement improvements. Evaluate effectiveness of processes; recommend and implement enhancements. Lead or support continuous process improvement initiatives.
4. Utilize departmental tools and reports to monitor performance. Analyze data trends to guide decisions and process changes.
5. Liaise with other departments to support cross-functional needs. Coordinate with Training teams to address knowledge gaps. Act as a subject matter expert for internal and external partners.
6. Support implementation of new systems or updates. Provide feedback for user testing and system enhancement.
7. Hire, train, and manage support staff, while monitoring and evaluating outcomes. Conduct performance reviews of each Team Member within IEHP guidelines.
8. Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

Education & Requirements 

• Minimum of four (4) years of medical claims processing experience, of which at least two (2) years of experience in a supervisory capacity leading a team
• This should also be inclusive of three (3) years of experience in a managed care environment
• The person in this role should also be experienced in benefit and financial matrix interpretation.
• Experience in an HMO or Managed Care setting. Medicare, Commercial and/or Medi-Cal experience preferred. Prior experience in a lead role or customer service environment is a plus
• High School diploma or GED required
• Bachelor's degree from an accredited institution preferred

Key Qualifications

• A thorough understanding of claims industry and customer service standards
• Knowledge in CMS, DHMC and DHCS regulatory guidelines including AB1455
• Extensive knowledge of ICD-9, ICD-10, CPT, and Revenue Codes
• Solid understanding of the DHCS, DMHC and CMS rules and regulations governing claims adjudication practices and procedures desired
• Knowledge in Commercial and Exchange policy and procedures
• Principles and techniques of supervision and training
• Knowledge of medical terminology and understanding of healthcare claims
• Analytical skills with emphasis on time management, database maintenance, spreadsheet manipulation, and problem solving
• Strong writing, organizational, project management, and communication skills proficiency required
• Excellent interpersonal and communication skills
• Must have a high degree of patience and ability to lead a large team of professionals

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

Telecommute (All IEHP positions approved for telecommute work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership)