Inspired? Hungry for an opportunity to use your talents supporting the greater good in your own community? Join us. We’ll transform healthcare in the Bay Area—together.
While we've been named an "Elite" Medical Group for 12 consecutive years, our goal is to expand our impact and remain on the cutting edge. We recently underwent a radical transformation, and now it's time to grow!
- 5 weeks of combined paid time off
- Potential for a $100k salary (with the right experience)
- 401k w/ employer matching
- Tuition reimbursement
- Practically free medical/dental
- Free on-site Yoga classes and massages :-)
If working with highly forward thinking leaders, and thoughtful professionals who value good ideas sounds motivating to you, this might be the right opportunity!
This position is responsible and accountable for the supervision and performance management of Claims Quality, Appeals and Recovery staff as well as overseeing day to day operations of the Claims Quality Assurance team. Manage internal claims audit processes and workflows to ensure consistent qualitative compliance with BTP policies/contracts and State, Federal and Health Plan regulatory requirements. Responsible for identifying claims transaction inconsistencies, as well as implementation of controls and changes to systems and policies that support claims adjudication, thereby minimizing incorrect claims payment.
Develops and implements work plans with actionable components and measurable outcomes using continuous improvement processes. Proactively monitors key performance indicators and displays that information through dashboards and metrics and makes real time adjustments to ensure that projects stay on track. Manage provider and member appeal policies and workflows to include compliance with internal service level agreements and State, Federal and Health Plan regulatory timeliness/qualitative requirements. Responsible for ensuring staff compliance with Brown and Toland recovery policies.
- Monitor and review work of all Claims Quality, Appeals and Recovery staff to identify additional training needs and to ensure compliance with department quality/production standards. Provides performance feedback, as well as identifies developmental opportunities for Claims Quality, Appeals and Recovery staff.
- Monitor and review claims audit and transaction reports. Responsible for identifying claims error trends, implementing controls and changes that will minimize incorrect claims adjudication. Coordinate potential recovery efforts with Brown and Toland Accounting and coordinate potential physician education opportunities with Brown and Toland Physician Services.
- Work closely with other Brown and Toland departments to ensure that all areas supporting claims meet appropriate claims quality goals.
- Ensures that all legal, regulatory and policy requirements are met by keeping informed of changes and by implementing necessary controls and/or programs to meet requirements.
- 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.
- In collaboration with the Claims QA and Training Specialist, Supervisor, responsible for ensuring that Claims Representatives have a thorough understanding of Brown and Toland claims adjudication policies and procedures.
- Coordinate provider contract, health plan benefit/DOFR and system rules configuration testing with Business Applications Configuration team.
- 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.
- Work with the Brown and Toland departments on implementing controls to minimize claims overpayments and identify physician education opportunities with Network Management.
- Work closely with other Brown and Toland departments and specifically, the Claims QA and Training Specialist to communicate findings of recovery audits and to facilitate accurate adjudication of claims.
- Supervise direct reports by assigning/directing work; conducting employee evaluations, staff training and development, taking appropriate disciplinary/corrective actions and making hiring/termination recommendations. Mentor team members in both technical and functional areas to provide growth opportunities.
- Must have a minimum of 5 years of claims experience working for either a Medical Group, IPA, MSO, or Health Plan. Time spent working in worker's comp, life insurance, or auto, will not be considered towards the minimum requirements.
- Must have previous supervisory experience such as Claims Supervisor Lead Claims Examiner / Lead Claims Processor, Claims Auditor, or Claims Manager.
- Advanced knowledge of and working experience with healthcare coding conventions such as ICD-10, CPT, and HCPCS
- Thorough knowledge of medical 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 configuration and architecture, which will facilitate troubleshooting of claims transaction related issues.