Supervisor, Capitation Claims

SUPERVISOR, CAPITATION CLAIMS

PVHMC incl. Offsite Facilities, POMONA, CA

Req# 19182

FINANCE ADMINISTRATION

Full time, 1 - Days, Days

Pomona Valley Hospital Medical Center is seeking an enthusiastic and adaptable Manager to join our team. This primarily in-person role offers some flexibility for remote work, providing a blend of onsite leadership with the option for remote work for the right candidate.

Job Summary: Under the guidance of the Director of Managed Care, the Claims Supervisor is responsible for managing the daily operations, performance, and regulatory compliance of the Hospital’s Capitation Claims Department. This role provides supervision of claims processing staff, maintenance of the claim adjudication software system and interaction with the system vendor as needed. Must effectively manage the claims inventory and provide timely and accurate claims and encounter processing. Responsible for compliance-related reporting and audits and coordination with other hospital department staff. Interaction with PVHMC’s affiliated medical group, and other functions may be required to maintain compliance with state and federal regulations, departmental standards and organization values. Assists management in the implementation of new business objectives, EZ-Cap upgrades, and other technical and vendor implementations related to claim processing. Responsible for monitoring updates for Coding and Medicare Fee Schedules and coordinating implementation with IT Department. Develop and modify policies and procedures, as needed. Responsible for a full range of activities, which may include claims processing, to ensure the operational effectiveness and excellence of the claims department.
May perform other duties as assigned.

Required Qualifications: High school or equivalent. Three (3) or more years of supervisory experience. At least five (5) years of Medicare Advantage Claims Processing Experience. Knowledge of CPT, RBRVS, HCPCS, ICD-10 and Revenue Codes. Extensive knowledge of claims processing for facility, professional and ancillary services, including identification of billing errors, and appropriate application of state and federal laws and regulations, contract terms, coordination of benefits and third-party liability. Experienced in benefit and financial matrix interpretation. Ability to interpret and apply rules and regulations governing claims adjudication practices and procedures. Requires excellent communication skills and proficiency in Microsoft Word, Excel and Crystal reports. Demonstrated knowledge of Provider Dispute Resolution process. Requires experience supporting regulatory and delegation audits.

Preferred Qualifications: Bachelor's Degree

Salary range: $80,000 — $93,000. annually. Salary will be commensurate with experience.

As part of our ongoing effort to remain an employer of choice, eligible employees who work qualifying weekend shifts receive a competitive weekend rate.