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Claims QA Supervisor II

Job Ref: 52897
Category: Claims
Department: CLAIMS
Location: New York, NY
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $60,000.00
Salary Range: $60,000.00 - $68,000.00

Marketing Statement

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. 

Position Overview 

The QA Supervisor Auditor provides day to day supervision to the Senior Claim Auditor and the Claims Auditors in reference to the auditing and reporting of complex, difficult and non-routine claims for multiple lines of business including vendor auditing. Ensuring that through the auditing process that system benefit configuration, claims compliance requirements, auditing and analysis related to claims payment/denial are met. The incumbent will work closely with MHP Core Configuration, Medical Management, Network Relations and Beacon.

Job Description

  • Under the direction and with wide latitude for the exercise of independent initiative and judgement, direct and/or coordinate the administration aspects of the unit. 
  • Plan, supervise, track the work of staff trains and coaches’ employees.
  • Ensure that Claims are audited in a professional and confidential manner with a focus on accuracy, payment and clerical/statistical issues.
  • Monitor quality control initiatives within Claims Operations by auditing Claims Auditor findings.
  • Accumulate, analyze data and prepare reports as a basis for Claims Operations management decisions relative to various claims activities.
  • Participation in the development, testing and implementation of new and or revised system enhancement to ensure effective and efficient claims processing.
  • Assist in the Administration management of specified activities and function by carrying out assignments and undertaking studies involving the evaluation, documentation and review of identifying Gaps, trends, Root Causes and recommending Process Improvements based on analytical findings and assist in the resolution.
  • Assist in the planning, coordination, and review of the development, training and the updating of policies and procedures.
  • Serve as a resource; provide expertise and assistance on Quality Improvement by assisting in the implementation of new programs and projects by monitoring their operations effectiveness.
  • Attends staff meetings, inter-departmental conference and represents the Director of Claims Service at inter-departmental functions and programs.
  • Other duties as assigned by the Deputy, Director Claims Operations.

Minimum Qualifications

  • Bachelor's Degree or equivalent work experience required
  • Minimum two (2) to five (5) years Claims Supervisory experience
  • Minimum of two (2) to three (3) years of Claims Health Insurance Auditing experience
  • Excellent verbal and written communication skills
  • Excellent PC Skills
  • Excellent interpersonal skills
  • Analytical and problem-solving abilities sufficient to effectively define complex problems and solutions in a logical and organized manner.
  • Excellent oral and written communication skills.
  • Knowledge of policy/benefits (Medicaid, Medicare, Commercial)
  • Must have in-depth knowledge of the claims processing/examining/adjustment protocols and payment schemes.
  • Detail oriented with the ability to manage multiple assignments simultaneously
  • Vendor oversight auditing experience
  • Critical thinking and decision-making skills required
  • Billing/Coding experience strongly preferred.
  • Strong knowledge of Microsoft office tools including competency in word processing, spreadsheets, database and presentation software.
  • Knowledge of policy/benefits (Medicaid, Medicare, Commercial)
  • Must have in-depth knowledge of the claims processing/examining/adjustment protocols and payment schemes.
  • Detail oriented with the ability to manage multiple assignments simultaneously
  • Vendor oversight auditing experience
  • Critical thinking and decision-making skills required
  • Billing/Coding experience strongly preferred.
  • Strong knowledge of Microsoft office tools including competency in word processing, spreadsheets, database and presentation software.

Professional Competencies

  • Integrity and Trust
  • Customer Focus
  • Functional/Technical skills
  • Written/Oral Communication