Curative

Curative is searching for an experienced Claims Supervisor. This position successfully manages the day-to-day activities of the Claim Team. Performs all duties below while maintaining compliance and confidentiality and promoting the mission and philosophy of the organization.

ESSENTIAL DUTIES AND FUNCTIONS:

• Successfully manages the day-to-day operations of the Curative Claims Team
• Serves as a key point of contact for audits, claims payments, questions, and customer service.
• Ensure consistent training, auditing, and feedback is given to all staff.
• Consistently ensure the Claims Team meets/exceeds the following standards:
  • Claims processing turn around.
  • Procedural and financial accuracy
  • Payment Cycle Review
• Manage the repricing process for non-par and OON claims in accordance with turnaround time standards and client specifications.
• Work closely with IT, Medical Services, System Support, to ensure efficiency.
• Work with Accounting, Executive and HR departments to define needed processes.
• Reviews High Dollar Claims for completeness and approves or denies payment using established guidelines and making all required internal notifications.
• Clearly and concisely documents claim adjudication decisions in Claim Notes.
• Works with the System Configuration department to ensure proper benefit setup.
• Completes required sample of professional and facility claims to audit for accuracy, as required by the client.
• Completes focused audits for error trends identified during processing or pre-
• release audit.
• Identify claim analyst training opportunities and provider billing issues.
• Submits audit results to the Claims Manager for review and final submission to clients.
• Acts as claims team resource for claims questions and benefit interpretation.
• Provides claim staff training via email alerts and training sessions.
• Reviews results of all prospective/retrospective audits provided from various sources to ensure that claims processing is handled, as mandated, by client directives.
• Analyzes, tracks and trends provider, system setup and claim errors.
• Works on claims team projects and reporting, assigned.
• Assists with all groups for professional and facility claim processing.
• Attend departmental training when required or requested.
• Adheres to the rules and regulations of Curative as described in the Employee Handbook and as defined in the unit/department/clinic procedures.
• Performs other duties and projects assigned.

MINIMUM QUALIFICATIONS:

Education:

• High school diploma or equivalent. Bachelor’s /Associate degree preferred.

Experience:

• At least 3-5 years of Claims Supervisor and/or Management experience required, including HMO, PPO, ERISA, and government plans experience.
• Experience working with Health Edge- Health Rules Payer system, a variety of claims payment systems, processing of all claim types, to include hospital/facility, behavioral health, dental, vision, and professional medical claims. Experience working with the VBA claims system. Customer Service experience preferred.

Knowledge, Skills, and Abilities:

• Ability to communicate with all levels of staff.
• Advanced Knowledge of claim coding and editing rules
• Knowledge of TDI regulations and requirements for claims payments
• Knowledge of HIPPA regulations
• Knowledge of medical terminology, IDC-10 CPT, and HCPCS coding.
• Proficient computer skills to include Microsoft Office applications.
• Excellent verbal and written communication skills
• Ability to communicate clearly and effectively.
• Ability to sit for extended periods of time at a computer workstation.

PHYSICAL DEMANDS:

SEDENTARY (requires lifting to 10 lbs., carrying small objects)