Medical Claims Supervisor (Remote)

LOCATION: Remote - This is a home based, virtual position that operates on US Eastern Standard time within the hours of 8:30am-5:00pm EST. Vaya Health welcomes applications from NC, SC, GA, TN, VA, MD, and FL.

GENERAL STATEMENT OF JOB

The Claims Supervisor administers all accounting functions related to a designated area of physical and behavioral health medical claims processing to ensure providers receive timely and accurate payment. Supervision of claims adjudication through continuous monitoring and quality control measures. Finalize claims processed electronically for payment and reviewing claim adjudication results for both Title XIX and non-title XIX claims, payment, and denial patterns, ensuring adjudication accuracy in the claims processing system, adhering to policy and procedures, review and follow up of provider billing concerns, coordination among and follow up, and assure the expected level of customer service to Vaya's network of providers.

ESSENTIAL JOB FUNCTIONS

Administrative Supervision and Functions:

• Oversight of claims staff for claims adjudication activities; provide technical assistance and technical training to claims staff, keeps staff abreast of all changes involving claims adjudication and policies/procedures
• Ensure claims adjudication policies and procedures and workflows are current.
• Provide support to ensure timely resolution of provider concerns related to claims processing.
• supervise the claims specialists within the MIS department.
• Coordinate the recruitment/selection of new claims specialists and recommend new hires.
• Provide ongoing feedback to staff regarding job performance, performance evaluations, disciplinary action, approving and coordinating leave, coordinating work schedules, signing off and approving timesheets and travel forms.
• Conduct regularly scheduled staff meetings with all staff reporting to this position.

Claims Adjudication:

• Finalize claims processed for payment and maintain claims adjudication workflow, reconciliation, and quality control measures to meet or exceed prompt payment guidelines.
• Reconcile provider claims payments through quality control measures, generally accepted accounting principles and Vaya's policies and procedures.
• Assess Title XIX and non-Title XIX claims adjustments for correction or recoupment and will coordinate the recoupment process to ensure payment is recovered for inappropriately paid claims.

Customer Service:

• Maintain provider satisfaction by managing provider inquiries, providing information, and assistance
• Assist providers in resolving problem claims and system training issues.
• Resource for internal staff to resolve eligibility issues, authorization, overpayments, recoupment, or other provider issues related to claims payment.
• Coverage of specific functions to assist the Department as work demands may dictate.

Compliance and Quality Assurance:

• Review internal bulletins, forms, appropriate manuals and applicable revisions, and fee schedules to ensure compliance with established procedures and processes.
• Attend and participate in workshops and training sessions to improve technical competence.

KNOWLEDGE, SKILL & ABILITIES:

• Working knowledge of the Medicaid Waiver requirements, HCPCS, revenue codes, ICD-9/10, CMS-1500/UB-04 coding, compliance and software requirements used to adjudicate physical and behavioral health medical claims.
• Ability to handle large volume of work and to manage a desk with multiple priorities.
• Ability to work in a team atmosphere and in cooperation with others and be accountable for results.
• Ability to maintain confidential information.
• Ability to establish appropriate and respectful relationships/partnerships with providers served.
• Ability to work with a multi-disciplinary team approach.
• Ability to enter routine and repetitive batches of data from variety of source documents within structured time schedules.
• Strong organization skills, computer proficiency, including Microsoft Office.
• Ability to speak and write professionally.
• Ability to understand oral and written instructions.
• General knowledge of office procedures and methods.

QUALIFICATIONS & EDUCATION REQUIREMENTS

High school diploma or GED required. Associate degree in business administration, health administration, communications or related field preferred.

• A high school diploma or GED and four years' experience in healthcare processing medical claims/reimbursement with experience in Physical Health and/or Behavioral Health claims is required and one year supervisory/coordination experience in behavioral health, medical billing/coding or similar

OR

• Associate Degree and one year experience in claims/reimbursement and one year supervisory/coordination experience in behavioral health, medical billing/coding or similar

OR

PHYSICAL REQUIREMENTS:

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT: The person in this position must live in NC, SC, GA, TN, VA, MD, or FL.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled.

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.