As the Claims Supervisor for Sendero Health Plan, a Health Maintenance Organization (HMO), and other Health Plans based in Texas, you will oversee the efficient and accurate processing of healthcare claims while ensuring compliance with regulatory requirements and company policies. Your leadership will be vital in managing a team of claims specialists, fostering a culture of excellence, and optimizing processes to enhance customer satisfaction.

Essential Functions

• Claims Processing Oversight: Supervise the end-to-end claims processing operations, including intake, adjudication, and payment processes, to ensure accuracy, timeliness, and compliance.
• Team Leadership: Recruit, lead, mentor, and motivate a team of claims specialists to achieve performance targets, resolve complex issues, and maintain high productivity levels.
• Compliance Management: Coordinate with the Compliance Department to stay abreast of federal and state regulations governing claims processing in the healthcare industry, ensuring adherence to all legal requirements and company policies.
• Provider Relations: Collaborate with network providers and collaborating with the Sendero Network Team to resolve claims-related inquiries, disputes, and grievances, fostering positive relationships, and promoting efficient communication channels.
• Performance Analysis: Analyze claims data and performance metrics to identify trends, root causes of errors, and opportunities for process improvement, implementing corrective actions as needed.
• System Enhancements: Partner with IT teams to evaluate, test, and implement system enhancements or updates to streamline claims processing workflows and enhance system functionality.
• Client Services: Ensure exceptional client service standards by promptly addressing inquiries, escalations, and complaints related to claims processing, striving to achieve high levels of member satisfaction.
• Training and Development: Develop and deliver training programs for claims staff to enhance their technical skills, regulatory knowledge, and customer service abilities, fostering a culture of continuous learning and professional development.

Knowledge, Skills and Abilities

• Strong understanding of healthcare claims processing principles, coding systems, and reimbursement methodologies. 
• Proficiency in utilizing claims processing software and systems (VBA preferrable), with a track record of driving system enhancements and process improvements. 
• Excellent leadership, communication, and interpersonal skills, with the ability to inspire and motivate teams to achieve organizational goals. 
• Thorough knowledge of healthcare regulatory compliance requirements, including HIPAA, CMS guidelines, and Texas regulations.
• Demonstrated ability to effectively manage multiple priorities in a fast-paced environment while maintaining attention to detail and accuracy.

Minimum Education:

• High School Diploma or equivalent (higher degree accepted)

Minimum Experience: 

• Minimum of 3 years of experience in health plan claims management or supervision, preferably within an HMO or managed care environment.
  And
• 7 years Minimum of 7 years of experience in health plan claims adjudication, preferably within an HMO or managed care environment. 

Required Licenses/Certifications:

• Certified Professional Coder.