If you're ready to be part of our legacy of hope and innovation, we encourage you to take the first step and explore our current job openings. Your best is waiting to be discovered. Day - 08 Hour (United States of America) **This is a Stanford Health Care job.** **A Brief Overview** This position is responsible and accountable for the supervision and performance management of Claims Auditor/Trainers and Claims Examiner III's, as well as overseeing day to day operations of the Claims Quality Assurance team. Responsible and accountable for ensuring Claims department compliance with Stanford Medicine Partners (SMP) claims processing policies. Ensures overall claims adjudication is in accordance with State, Federal and Health plan regulatory requirements and guidelines. Develop training programs for Claims Examiners. Provide organization and a unified structure to the claims transaction review process. Responsible for identifying claims transaction inconsistencies, as well as implementation of controls and changes to systems and policies that support claims adjudication, thereby minimizing incorrect claims payment. **Locations** Stanford Health Care **What you will do** + **Staff Supervision** + Supervises subordinate personnel including: hiring, determining workload and delegating assignments, training, monitoring and evaluating performance, and initiating corrective and/or disciplinary actions. + Responsible for ensuring staff compliance with corporate and departmental policies and procedures. + Provides first level input for developmental goals and evaluations for Claims Auditors/Trainers and Claim Examiner III’s, to include drafts of employee evaluations. + Plan, organize and direct overall workplace functions; coordinate time, vacation schedules and staff coverage; establish departmental procedures. + Monitor and review quality and audit reports to identify additional training needs and to ensure compliance with Claims department quality standards. + **Administration & Personnel** + Responsible for developing and administering measurement devices, including tests and post training evaluations to determine the level of trainee performance and training effectiveness achieved. Serve as the primary point of contact to answer questions related to various claim issues and resolve non-routine, complex claim/benefit adjudication issues for department staff as well as other internal customers. + Work closely with other SMP departments to ensure that all areas supporting claims meet appropriate claims quality goals. + **Compliance** + Reviews operational reports to ensure compliance with State, Federal and Health plan regulatory requirements. + Ensures that all legal, regulatory and policy requirements are met by keeping informed of changes and by implementing necessary controls and/or programs to meet requirements. + Exhibits a thorough understanding of industry standard claims processing guidelines. + In collaboration with the Claims Supervisor, responsible for ensuring that Claims Examiners have a thorough understanding of SMP claims adjudication policies and procedures. + Facilitate Health plan claims audits as well assist with other external audits, e.g., annual financial audits. Develop corrective action plans that address negative audit findings. + Preparation and timely submission of timeliness and regulatory reports. + **Collaboration & Communication** + Collaborates and effectively interfaces with all departments and employee levels to ensure optimal results and productive working relationships. + Responsible for the identification and resolution of provider claim issues including support of Network Management and Customer Service staff in communications back to providers. + Work with the Recovery department on implementing controls to minimize overpayment and identify physician education opportunities with Network Management. + All other duties as assigned including department-specific functions and responsibilities + Performs other duties as assigned and participates in organization projects as assigned. + Adheres to safety, P4P’s (if applicable), HIPAA and compliance policies. **Education Qualifications** + High school graduate **Experience Qualifications** + Seven (7) years prior claims processing and auditing experience in an IPA or HMO related setting with a minimum of two (2) years in a supervisory capacity + Working understanding of basic computer operations and medical insurance rules/regulations + Thorough knowledge of medical terminology, claim processing procedures/systems, auditing, and a thorough understanding of claim protocols, industry standards and CMS regulations as it relates to claims payment and compliance. Advanced knowledge of claims processing systems architecture, which will facilitate troubleshooting of claims transaction related issues. + Basic understanding of Microsoft Word and Excel applications + Advanced knowledge of and working experience with ICD-10, CPT and HCPC coding systems **Required Knowledge, Skills and Abilities** + Supervise others by assigning/directing work; conducting employee evaluations, staff training and development, taking appropriate disciplinary/corrective actions and making hiring/termination recommendations. + Effective oral and written communication skills. + Able to assess and coordinate departmental workflows effectively. + Ability to train using instructional material. Ability to write procedural updates and clarifications of policies. + Relies on extensive experience and judgment to plan and accomplish goals. + A wide degree of creativity and latitude is expected. + Ability to work independently, and organize and prioritize work. + Independent decision making skills and demonstrated ability to take initiative to resolve issues **Physical Demands and Work Conditions** **Physical Demands** + Constant Sitting. + Frequent Walking. + Occasional Standing. + Occasional Bending. + Occasional Squatting. + Occasional Climbing. + Occasional Kneeling. + Seldom Crawling. + Constant Hand Use. + Constant Repetitive Motion Hand Use. + Frequent Grasping. + Occasional Fine Manipulation. + Frequent Pushing and Pulling. + Occasional Reaching (above shoulder level). + Frequent Twisting and Turning (Neck and Waist). + Constant Vision (Color, Peripheral, Distance, Focus). **Lifting** + Frequent lifting of 0 - 10 lbs. + Occasional lifting of 11 - 20 lbs. + Seldom lifting of 21 - 30 lbs. + Seldom lifting of 31 - 40 lbs. + Seldom lifting of 40+ lbs. **Carrying** + Frequent lifting of 0 - 10 lbs. + Occasional lifting of 11 - 20 lbs. + Seldom lifting of 21 - 30 lbs. + Seldom lifting of 31 - 40 lbs. + Seldom lifting of 40+ lbs. **Working Environment** + Occasional Driving cars, trucks, forklifts and other equipment. + Constant Working around equipment and machinery. + Seldom Walking on uneven ground. + Seldom Exposure to excessive noise. + Seldom Exposure to extremes in temperature, humidity or wetness. + Seldom Exposure to dust, gas, fumes or chemicals. + Seldom Working at heights. + Seldom Operation of foot controls or repetitive foot movement. + Seldom Use of special visual or auditory protective equipment. + Seldom Use of respirator. + Never Working with biohazards such as blood borne pathogens, hospital waste, etc.. **Blood Borne Pathogens** + Category III - Tasks that involve NO exposure to blood, body fluids or tissues, and Category I tasks that are not a condition of employment **Travel Requirements** + 10% travel: **These principles apply to ALL employees:** **SHC Commitment to Providing an Exceptional Patient & Family Experience** _Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery._ _You will do this by executing against our three experience pillars, from the patient and family’s perspective:_ + Know Me: Anticipate my needs and status to deliver effective care + Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health + Coordinate for Me: Own the complexity of my care through coordination **Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in** **all of** **its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.** Base Pay Scale: Generally starting at $46.85 - $60.90 per hour The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage. At Stanford Health Care, we seek to provide patients with the very best in diagnosis and treatment, with outstanding quality, compassion and coordination. With an unmatched track record of scientific discovery, technological innovation and translational medicine, Stanford Medicine physicians are pioneering leading edge therapies today that will change the way health care is delivered tomorrow. As part of our spirit of discovery, we also leverage our deep relationships with luminary Silicon Valley companies to develop new ways to deliver preeminent patient care. Learn about our awards (https://stanfordhealthcare.org/about-us/awards.html) and significant events (https://stanfordhealthcare.org/about-us/our-history.html) .