Medical Claims Supervisor

Job Title: Medical Claims Supervisor 

FLSA Status: Exempt

Salary Range: See Pay Scale 

Job Summary: The Medical Claims Supervisor manages the Medical Authorization team and is responsible for overseeing medical claims processing activities, monitoring pending and aged claims inventories, researching claim issues, and ensuring timely and accurate adjudication of claims in accordance with health plan benefits, provider contracts, regulatory requirements, and internal performance standards. The position reports directly to the Director of Finance. This position works closely with claims operations, finance, compliance, quality, IT, provider relations, member services, contracted providers, facilities, vendors, and leadership to ensure accurate and timely processing of claims and resolution of claims-related issues.

Education: Bachelor's degree preferred; associate degree in healthcare administration, business administration, health information management, medical billing and coding, or related field preferred.

Experience: Minimum five years of experience in medical claims processing, claims adjudication, health plan operations, payer operations, or provider billing. Experience monitoring claims inventories, denied claims, payer worklists, and claims processing workflows. At least 1 years experience working with the frail elderly population. 

Number and Type of Employees Supervised (optional): 2-4 employees. 

Licensure, Registry or Certification Required: None 

Special Training: Meet a standardized set of competencies for the specific position description established by Senior TLC, Inc. and approved by CMS before working independently. Working knowledge of health insurance operations, claims adjudication, benefit interpretation, provider contracts, denials, reconsiderations, and appeals. Familiarity with CPT, ICD-10, HCPCS, Medicare, Medicaid, managed care plans, electronic claims systems, and payer portals.

 Immunizations: Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact

Ages of Patients Rendered Care: 

 Neonate/Infant Early Childhood Adolescent Adult Geriatric All Age Groups

· Supervise the Medical Authorization team and processes.

· Monitor claims adjudication queues, pending claims inventories, suspended claims, denied claims, corrected claims, and claims requiring manual review.

· Review claim status, member eligibility, benefit coverage, provider contract terms, coding information, claim edits, and supporting documentation to determine why claims are pending, delayed, denied, or not processing correctly.

· Research and resolve claims discrepancies including payment variances, benefit application issues, duplicate claims, coding errors, provider setup concerns, system edits, and member eligibility issues.

· Follow up with providers, facilities, vendors, claims processors, and internal departments to obtain necessary information and facilitate claim resolution.

· Document claims research, follow-up activities, communication, actions taken, escalation steps, and claim outcomes within health plan systems.

· Maintain tracking logs and reports for pending claims, aged claims, denial trends, turnaround times, and unresolved claims requiring management attention.

· Escalate complex or high-priority claims issues to leadership as appropriate.

· Assist with claims reprocessing, reconsideration requests, appeals, provider inquiries, member inquiries, and internal or external audits.

· Monitor compliance with health plan policies, claims processing standards, HIPAA requirements, and applicable Medicare, Medicaid, and managed care regulations.

· Collaborate with operations, compliance, finance, quality, and IT teams to identify workflow improvements and resolve recurring claims issues.

· Prepare and submit monthly reinsurance reports.

· Submit monthly outstanding inpatient claims reports for accrual processing.

· Monitor and resolve participant bills related to medical claims processing.

· Monitor key performance indicators (KPIs), claims inventory metrics, denial trends, turnaround times, and productivity measures.

· Supports Senior TLC’s mission to encourage and support the quality of life of seniors wishing to continue living in the community; its vision to be the preferred provider of individualized care for seniors in the community; and its values of respect, integrity, accountability, compatible goals, and compassionate care.

· Other duties as assigned.