To supervise the claims auditors; claims fraud, waste, and abuse coordinators and the related job functions for each position. Ensures delivery of highest level of customer service to the community and its medical providers.

• Supervises claims auditors and their job functions. Supervises the audit workflow. Supports claims audit functions. Maintains audit inventories within established goals.
• Supervises Claims Fraud, Waste, and Abuse Coordinators and their job functions. Works closely with Partnership Compliance Department.
• Reviews quality control audits to ensure compliance within established department guidelines and policies and procedures. Identifies errors and deficiencies, develops and implements corrective action and training plans for audit staff.
• Interviews and participates in the selection of qualified candidates for the claims audit positions. Trains new staff.
• Evaluates performance and provides developmental opportunities for staff. Counsels performance problems or issues when needed. Reviews and signs time sheets.
• Drafts important provider notices for Senior Claims Director’s review.
• Participates in the review of Claims Operating Memorandums, recommends changes for more efficient operations, communicates changes and updates to auditing staff when appropriate.
• Ensures that concurrent, retrospective, and special audits are completed accurately and timely. Reports outcomes to Claims Department Supervisors, Managers, Associate Directors, and Directors.
• Develops and implements training schedules for new Claims Examining and CSR staff with Claims Supervisors. Develops and updates Claims Examining and CSR training materials.
• Supervises and participates in Partnership delegated entity audits. Collects, monitors, tracks, and reports claims delegation reporting for capitated entities to the Partnership sub delegation committee. Attends Partnership sub delegation committee meetings.
• Other duties as assigned.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$93,690.86 - $117,113.58

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.