Claims Supervisor - Commack Stony Brook University

Stony Brook University
Stony Brook, New York
Full Time

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Required Qualifications (as evidenced by an attached resume):
Bachelor's degree (foreign equivalent or higher). In lieu of degree, four (4) years of full-time experience in medical claims processing may be considered. One (1) year of full-time medical claims processing experience with progressive leadership responsibilities. Experience with workers' compensation or federal government programs. Experience with electronic billing systems. Experience working with medical terminology, ICD-10 and CPT coding. Prior supervisory experience. Experience working with Word, Excel and/or Access.

Preferred Qualifications:
Three (3) years of full-time medical claims processing experience. Experience leading and/or supervising a small team. CPC certification. Experience with Patient Keeper, electronic medical records and scheduling systems. Experience in risk management and resolving claims related issues. Experience with the WTC Health Program.

Brief description of duties:
The Claims Supervisor is responsible for ensuring that all WTC-related claims are reviewed and submitted timely to the WTC Health Program for payment. The Claims Supervisor supervises a team of agents. The supervisor is also responsible for claims processing and dealing with difficult claims that are kicked up to the supervisor level. The supervisor manages and tracks these claims, seeing through to their resolution. The candidate will represent Stony Brook's Long Island Clinical Center of Excellence (CCE) to NIOSH who administers the WTC Health Program and to third party contractors who are involved with managing the claims process and payment to the providers and CCE. Strong communication, organizational and written skills. Strong sense of responsibility, initiative, and good judgment to work independently with minimal supervision.

Duties:

Management and Staff Supervision :

Supervise Claims team (hire, train, coach, review time and write performance reviews) which consists of claims specialists to ensure a cohesive and positive work environment, and the team meeting or exceeding all metrics.
Ensure that all contract requirements as they pertain to the claims area are being met.
Review and interpret performance reports.
Participate in leadership meetings and provide weekly reports to the Director at these meetings.
Provide written report to the Director and Deputy Director at least monthly, and as needed.
Work with the Care Management/Care coordination team to teach, guide decision-making and resolve coverage issues.
Provide constructive feedback when errors are made.
Assist in confirming codes for pre-authorization of services.
Provide both written guidance and presentations, as needed.
Ensure all departmental SOPs are updated regularly to reflect changes in operations.
Distribute and store WTCHP Codebooks (monthly) and HealthCare provider lists (weekly).
Participate in leadership meetings, including participation in the Quality Assurance Committee.

Claims Processing and Management:

Facilitate resolution of claims that do not meet standards and require outreach to vendors, providers, case management, or third-party contractors.
Work with the Deputy Director of Administration to resolve claim issues, including participating in regular meetings with the funding agency and other program contractors.
Work with the ICM team to track and report hospitalizations to NIOSH via the portal; review and ensure all codes will be covered.
Complete Code Addition request forms as required to ensure coverage for members' care, track and follow-up on outcomes.
Calculate and store FECA schedules in the Exchange on a quarterly basis.
Notify Stony Brook of rate changes.
Process dental claims and other standard claims.
Validate that claims are accurate and meet Program guidelines prior to releasing for payment.
Convert payment files weekly to correct format and merge with prior payment files (Flat files).
Manage all claims appeals (i.e. claims that exceed timely filing limits).
Manage all PA3 and dental claim submissions.

Network Provider Management:

Assist in the education of network vendors and providers on WTC coverage and coding.
Add providers, both external and internal to the WTCHP Healthcare network as needed.

Other duties or projects as assigned as appropriate to rank and departmental mission.

Special Notes:
The Research Foundation of SUNY is a private educational corporation. Employment is subject to the Research Foundation policies and procedures, sponsor guidelines and the availability of funding. FLSA Exempt position, not eligible for the overtime provisions of the FLSA. Minimum salary threshold must be met to maintain FLSA exemption.

**The incumbent must be willing to work and travel between the Westbury and Commack clinic locations. Occasional Evenings and Saturdays will be required.

For this position, we are unable to sponsor candidates for work visas.

Resume/CV and cover letter should be included with the online application.

Stony Brook University is committed to excellence in diversity and the creation of an inclusive learning, and working environment. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, pregnancy, familial status, sexual orientation, gender identity or expression, age, disability, genetic information, veteran status and all other protected classes under federal or state laws.

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The starting salary range (or hiring range) to be offered for this position is noted below, it represents SBU's good faith and reasonable estimate of the range of possible compensation at the time of posting.