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Appeals Supervisor

Date:  May 11, 2022
Location: 

West Sacramento, CA, US, 95605-1630

Req ID:  7456

Summary

The Medi-Cal program is to provide essential medical care and services to preserve health, alleviate sickness, and mitigate handicapping conditions for individuals or families on public assistance, or whose income is not sufficient to meet their individual needs. The covered services are generally recognized as standard medical services required in the treatment or prevention of diseases, disability, infirmity or impairment. These services are comprehensive and provide care in the major disciplines of health care.

The Appeals Supervisor will provide oversight to the final step in the administrative process for Medi-Cal providers to resolve claim problems for unsatisfactory responses to processing, payment or resubmission of a claim.  Each case is reviewed on its own merit using applicable history files and based on documentation submitted with the appeal. 

The Supervisor directly reports to the Director of the Claims Operations and is an integral member of the Claims Leadership Team. The Appeals Supervisor will conduct the management of appeal claims in the utmost of good faith in compliance with the rules, regulations, and statutes of the Department of Health Service.

The Supervisor is responsible for staff training and development. The Supervisor will work closely with other members of Claims Leadership to insure the efficient and effective resolution of issues. The Supervisor is expected to function at a high level of expertise and competency, while consistently exercising good judgment and independent discretion. The Supervisor is expected to support Company goals, Department Goals and advance Company values.

In this role utilize your prior claims and management experience to achieve business plan goals and to ensure compliance, policy provisions and company guidelines while fostering a culture of communication.

Job Description

Responsibilities:

  • Manages the assignment claims staff and provide direction and ongoing guidance through effective daily management.
  • Ensures timely, accurate completion of claim activity.
  • Selects, trains, coaches, and mentor’s unit personnel.
  • Monitor performance of employees.  
  • Plans staff responsibilities and directs activities, utilizing staff resources effectively to meet department goals in accordance with the contract requirements. 
  • Develops staff to respond to current and anticipated needs of department as well as determining career development goals of individuals.
  • Develops, recommends, and implements short range objectives consistent with company business goals.
  • Recognizes and analyzes trends across the claim’s portfolio at the unit level.
  • Reports on observations and recommends remedial action as needed.
  • Administers salary under guidance of manager.
  • Identify and resolve operational problems.
  • Utilizes quality assurance to develop opportunities for improvement.
  • Utilizes performance management process effectively, on an ongoing basis, to maximize performance of employees, correct performance problems, provide development opportunities, and promote effective communication with employees.
  • Promotes effective communication among and between team members, and between management and employees.
  • Demonstrated ability to work independently and establish and accomplish team goals.
  • Demonstrate commitment to Company’s Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards, and laws applicable to job responsibilities in the performance of work.
  • Ensure task completion and performance goals are met, such as Quality, Adherence, service levels.
  • Minimum of three years of work experience in an insurance related industry required.
  • Demonstrated leadership, coaching, mentoring and teamwork skills.
  • Advanced skills in applying sound judgment/analysis, decision making/problem solving, planning and organization.
  • Excellent verbal and written communication skills.
  • Build a trusting customer relationship through transparency, partnership and communication. 
  • Excellent customer service and collaboration skills gained through previous work experience.

Job Description

Education/Experience:

  • Two or more years in a supervisory capacity including hiring, training, assigning work and managing the performance of staff.
  • Two or more years of experience in operations management, financial management or analysis, or claims operations experience
  • Strong organizational/time management skills and ability to multi-task while maintaining attention to detail.
  • Minimum of three years of work experience in an insurance related industry required.

 

Work Environment

  • Office environment

Qualifications

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