Supervisor, Claims Appeals & Recovery

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You Will Focus On

• Manage and update claims audit and PDR/appeals/health plan cap deduct policies, workflows and processes to ensure compliance with Claims department and State, Federal and Health Plan quality standards. Provide analysis of claims quality adjudication results and identify training opportunities for Claims Reps.
• Responsible for ensuring accurate reporting and timely submission of quarterly PDR timeliness reports.
• Responsible for the preparation, coordination, and facilitation of external party PDR and adjustment audits. Responsible for development of any corrective action plans (CAPs) that result from PDR and adjustment audit findings.
• Responsible for monitoring progress and application of documented CAPs.
• Responsible for developing and administering measurement tools to effectively monitor recovery activities. Serve as the primary point of contact to answer questions related to various recovery issues and resolve non-routine, complex recovery issues for department staff as well as other internal customers.
• Work with the Brown and Toland departments and BPO on implementing controls to minimize claims overpayments and identify physician education opportunities with Network Management.
• Work closely with BPO and other Brown and Toland departments (e.g., Operational Integrity team) to communicate findings of recovery audits and to facilitate accurate adjudication of claims.
• Collaborates and effectively interfaces with all departments and employee levels to ensure optimal results and productive working relationships.

The Skills, Experience & Education You Bring

• Seven (7) years prior claims processing experience in an IPA or HMO related setting, with a minimum two (2) years in a lead or supervisory capacity.
• Experience with Epic/Tapestry system preferred.
• Seven (7) years knowledge of and working experience with ICD-10, CPT and HCPC coding systems.
• Working understanding of basic computer operations and medical insurance rules/regulations
• Thorough knowledge of medical terminology, claim processing procedures/systems, auditing, and a thorough understanding of claim protocols, industry standards and CMS regulations as it relates to claims payment and compliance. Advanced knowledge of claims processing systems architecture, which will facilitate troubleshooting of claims transaction related issues.