Claims Operations Delegation Oversight, Supervisor

The Claims Operations Supervisor of Delegation Oversight position plays an important, strategic client relationship role for IPA/hospital clients; their Health Plans; regulators; and claims operational areas. The Claims Operations Supervisor reports directly to the Senior Manager of Claims Operations, but also works closely with the Compliance Officer to execute primary responsibilities.

Duties:

Manage all Claims external audits/requests for information from business partners, ensuring consistent accuracy, timeliness, and compliant submissions
Collaborates with internal SMEs from functional areas, who are liaisons to Claims and Compliance
Ensuring the data integrity and timeliness of all Claims audit requests (pre- and post-audits)
Develop and maintain monitoring methods and tools to self-identify and correct potential non-compliant claims
information (e.g., universes, sampled case files, CAPs)
Support Claims team in developing root cause analysis and potential solutions to corrective action plans (CAPs)
requested from auditors/clients
Create and maintain P&Ps that document Claims methods and protocols
Working with functional SMEs, develop KPI reporting to perform ongoing internal monitoring, compliant
performance for all Claims operational areas
Assist with dashboard KPI reporting for Claims, Executive leadership, and Compliance, including proactive trend analysis to prevent/detect timely potentially noncompliant Claims scenarios
Collaborate with Claims and other departments to pull together audit findings and provide oversight and monitoring when audits are completed and compliant
Serve as the Claims representative in key Compliance meetings (i.e., weekly Compliance Huddles, Delegation Oversight Committee, and Compliance Committee), presenting Claims performance results, as necessary
Pay: $70-80k, could maybe go above for a really strong candidate (87k MAX)

Work Environment:

Erica would like for them to be hybrid-ish - they can be mostly remote but must be flexible to come in (especially if they have an onsite audit, likely once/twice a year) so would prefer local candidate (however, Erica they doesn't want to fully cut if off completely if we have someone qualified that is not immediately local)
Selling Points
Great office, they are very big on culture. They have their core values displayed on the walls throughout the office (a lot of similarities to Medix)
They get points via Awards Co that translate into dollars they can use on Amazon, for hotels, concerts, and more
Swag bag when they start with different Medpoint swag
401k matching 100% up to 5% of their salary
Potential for bonuses at the end of year based on performance
Annual merit increases
When they hit 10 year = $2,500 and a week of PTO
20 years = $5k and a week of PTO
30 years = $10k and a week of PTO
3-5 Must Have Skills/Qualifications
2-3+ years of experience working in claims operations with a focus on compliance/operations (Someone who has worked in a delegation oversight department of a health plan - cannot be a normal claims auditor, must be within delegation oversight dept)
Must have Medi-Cal and Medicare experience
Experience with a health plan or another MSO in delegate oversight
Experience reading CAPs
Knowledgeable in regulatory requirements
Soft Skill/Attribute Requirements
Professional and polished
Someone who is confident (they will be the face of the company when the health plans audit)
Interview Availability
Send subs to Adreanna and Nimra
Multiple interviews: 1st interview with Linda, 2nd interview with Erica (both virtual
Commitment to 24-48 hours sub/interview follow up
Yes

Schedule/Shift
Hours: typically 8am-5pm but depending on business needs need to be flexible for a little earlier or later

For California Applicants:

We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).

This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.