Claims Supervisor - On Site at Prospect Medical Systems - CA in Orange, California

Job Description:

Claims Supervisor

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

Monitors day to day claims inventory to ensure all CMS and DMHC regulatory guidelines are met. Serves as direct Supervisor to claims personnel. Has direct responsibility for overseeing all claims processing functions for all LOB, both Profession and Institutional. Identifies and adopts appropriate solutions and changes necessary to establish and maintain high levels of quality and service. Motivate and counseling staff when necessary. Also responsible for coordinating inventory and mailroom resources to fulfill and process all incoming mail. Responsible for supervising the inventory and mail staff to meet established performance measures for timely processing. Selects, develops, and evaluates personnel to ensure the efficient operation of the functions.

Job Responsibilities/Duties

• Monitors daily inventory Dashboards to ensure that departmental goals are met. Works with Director to plan daily workflow. Reviews and approves High Dollar claim payments to providers daily. Provides management with feedback of overall inventory compliance.
• Oversee daily mailroom activities including sorting, batching of incoming mail, as well as preparation and sending of outgoing mail to our scanning vendor.
• Ensure the preparation of medical records/Appeals for in our in-house scanning vendor.
• Ensure PDRs are looked up and batched appropriately for the PDR Team.
• Oversees and directs the day-to-day operations of the Data Entry staff.
• Ensures adequate staffing levels are always maintained.
• Provide weekly reports to upper Management on the status of the Mail Room.
• Train and develop Mail Room employees to work as team.
• Coaching and developing existing staff.
• Oversight of Team performance metrics.
• Do weekly one on ones with staff.
• Provides written communication to other departments as needed regarding pended claims inventory.
• Prioritizing and distribution of work to claims staff.
• Monitor production to ensure claim production standards and quality standards are being met.
• Answers claim questions for staff.
• Responsible for accurate file management, archiving and storage PDRs and medical records for 90 days.
• Responsible for coordination with Facilities Director of vendor shredding and the security associated for the protection of records to be shredded.
• Prepares and conducts Performance Reviews and Disciplinary Action for staff.
• Identifies ways to control cost by evaluating, analyzing, and researching payment trends and variances.
• Recommends polices and procedure changes regarding claim payment processing.
• Handles other duties as needed.

Qualifications

Minimum Education: Bachelor's Degree preferred or High School diploma with two to three (2-3) years claims Management experience.

Minimum Experience: PC skills, knowledge of word processing/spreadsheet applications. Working knowledge of workflows. Five years' experience in an IPA or MSO setting required. One (1) years' experience working over a Mail room setting preferred. IDX experience highly desirable.

Req. Certification/Licensure: None.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals, benefit eligible positions will receive:

• Company 401K
• Medical, dental, vision insurance
• Paid time-off
• Life insurance

Prospect Medical Systems has a zero-tolerance policy regarding the use of drugs and alcohol. Our Company is committed to maintaining a productive, drug free workplace that keeps employees and patients safe from harm. For this reason, we require applicants to pass a screening for drug use as a condition of employment. This includes: alcohol, marijuana, cocaine, opiates and methamphetamines.

How to Apply

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www.eeoc.gov/

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