Job description 

Job title Unit Manager (Band4/ Level5)

Reports to Ops Manager

Under the supervision of the Claims Manager, the Claims Supervisor is responsible for providing support, direction and supervision to Claims Examiners. This position also monitors and supervises various processes throughout the claims cycle and may process claims for assigned groups.

Technical Skills:

 Monitors claims inventory daily; manages inventory to ensure claims are being processed in a timely manner

 Processes overpayments, underpayments, and refund checks

 Reviews appeals and assists with determination

 Reviews and approves weekly claim batches

 Monitors weekly pend report process

 Monitors weekly pre-check register process

 Assists with researching escalated provider services/client services claims inquiries

 Assists with organization and facilitation of department meetings

Process Skills:

 Responds to examiner questions and tracks question trends

 Assists with providing training for new and existing examiners and assistants

 Provides ongoing feedback and support to improve performance of direct reports

 Prepares and facilitates performance reviews for direct reports

 Reviews and approves time cards and PTO requests for direct reports

 Assists with the identification and selection of new employees

 Communicates clearly and concisely, with sensitivity to the needs of others

 Assists with special projects, as requested

 Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees

 Maintains courteous, helpful and professional behavior on the job

 Establishes and maintains effective working relationships with co-workers

 Follows and ensures departmental compliance with all Policies and Procedures and HIPAA regulations

 Maintains knowledge and understanding of current Medicare claims processing guidelines

 Attends continuing education seminars/training as requested

 Maintains a safe working environment

Behavioral Skills :

 Ability to work independently with minimal supervision

 Ability to independently follow through on projects

 Ability to communicate professionally, clearly and effectively, verbally and in writing

 Ability to prioritize effectively

 Ability to consistently multitask

Certification:

 Educational requirements include a High School Diploma or equivalent. A minimum of three years of claims processing experience is preferred. A minimum of one year of supervisory experience is required, preferably in health plan operations.

 Solid understanding of CMS-1500 & UB-04 guidelines

 Strong working knowledge of CPT, ICD-10, and HCPCS coding, including modifiers

 Familiarity with APC and DRG reimbursement

 Knowledge of EDI claims

 Knowledge and experience using current computer technology, including experience with Excel and Word.

 Skilled in establishing and maintaining effective working relationships with clients, and staff at all levels

 Skilled in data analysis and problem solving using defined methodologies

 Skilled in problem resolution; recommends suggestions to increase accuracy and/or efficiency

Skills

PRIMARY COMPETENCY : Healthcare PRIMARY SKILL : Healthcare-Claims Adjudication PRIMARY SKILL PERCENTAGE : 100