Healthcare Claims and Fee for Service Supervisor

Position Summary

The Claims and Fee for Service Supervisor manages the operational activities and staff of the Claims and Revenue Cycle Department in accordance with company guidelines, client needs, and state and federal requirements.

Duties and Responsibilities

• Oversee and manage daily activities and functions of Claims Examiners processing capitated and fee-for-service claims with the health plan.
• Manage daily Revenue Cycle Management and Claims department operations, including reporting, timely claims processing, compliance, and 835 payment posting.
• Develop, implement, and update claims policies and procedures to ensure compliance with CMS, Medicaid, HIPAA regulations, and health plan requirements.
• Report overpayments, underpayments, and other irregularities.
• Manage and close claim open tickets and provider disputes.
• Ensure optimal claims handling, investigate claims issues, and provide claims training for business units.
• Partner with Provider Servicing and participate in provider education as needed.
• Maintain a strong understanding of covered benefits, coding, reimbursement policies, and contracts.
• Serve as a subject matter expert in claims processing, payment dispute resolution, cost containment, audit processes, and contract interpretation.
• Collaborate with management and staff to improve operational efficiency and best practices.
• Analyze claims payment processes to ensure system configuration accuracy and proper provider payments.
• Investigate and resolve problem claims and reduce future errors.
• Execute claims process testing requests to support accurate claims payments.
• Analyze and adjudicate complex claims requiring supervisor review.
• Adjudicate claims by applying medical necessity guidelines, determining coverage, verifying eligibility, and applying cost containment measures.
• Process medical claims by approving or denying documentation, calculating benefits, and initiating payment or denial letters when necessary.
• Track CMS changes affecting claims processing.
• Perform pre-payment audits and support the payment cycle.
• Maintain performance standards, follow company policies, and ensure legal compliance.
• Stay current on claims knowledge through education, including medical coding and terminology.
• Maintain departmental and specialty network SOP standards.
• Meet regularly with the VP of Operations to resolve reimbursement and billing issues.
• Conduct one-on-one meetings with staff members.