Supervisor - Claims Delegation Oversight

Department: Claims

Employment Type: Full Time

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Reporting To: Randi Hanson

Compensation: $78,000 - $91,000 / year

Job Title:

Supervisor
- Claims Delegation Oversight

Department:
Ops
- Claims Ops

About the Role:

The Supervisor, Claims Delegation Oversight, is responsible for the management and oversight of all Claims Delegation Audits, including health plan and governing agencies audits, i.e., DMHC, CMS, and DHCS. This role will be responsible for the development and execution of department strategies, overall Audit program, Audit process optimization, and management, identifying and leveraging technology and data to improve the quality and minimizing process cost of Claims.

This position will contribute and influence overall Claims Delegation Oversight roadmap to ensure Claims Administrations are adhering to regulatory and internal guidelines as they apply to claims processing and adjudication. Working with Manager and Department Director.

External Audit planning, execution & support

• Develop and implement the operational strategy for driving all external audits for Astrana Health to ensure audit planning and readiness, successful audit execution and delivery, CAP management, and improve overall audit score
• Lead, monitor, and oversee the end-to-end lifecycle of all external audits, including but not limited to health plan audits, DMHC audits, CMS audits, etc
• Create, monitor, and manage metrics and goals for successful execution and management of all external audits
• Ensure Audit results are clearly tracked, trended, reported, and communicated timely and effectively
• Collaborate with the reporting team to ensure all universe listings are delivered timely and accurately
• Ensure all supporting documents are pulled timely and reviewed thoroughly prior to delivery
• Ensure a pre-audit is conducted for all external audits to gauge the health of an upcoming audit and to assure conformity with the internal health plan and regulatory guidelines and requirements
• Actively engage in Root Cause analysis of deficiencies, and lead efforts in the development and implementation of effective remediation and process improvement solutions.
• Collaborate with Claims operations to ensure any issues found as part of the pre-audit are readily remediated, including devising and implementation of root cause and prevention strategy
• Ensure corrective action plan (CAP) management for issues identified as part of all audits performed with clear root cause analysis and prevention plan
• Ensure all HP reports (scheduled and ad-hoc) are pulled timely and review/approve the accuracy of reports

Documentation, Training & Development

• Review and approve cross-functional/departmental External Audit process documentation, workflows, policies, and procedures, job aides, and standard operating procedures for completeness and accuracy
• Drive and ensure internal process adherence for creating/ maintaining cross-functional/departmental claims processes, workflows, policies, and procedures, job aides, and standard operating procedures
• Ensure adherence to all Legislative, Regulatory, and Contractual requirements
• Review, collaborate, and oversee the Training Plan & Training Strategy for the team, including measuring training effectiveness and remediation strategy
• Identify training needs/ gaps for the team and ensure timely and effective training is imparted to all team members

Collaboration

• Build and maintain productive & collaborative intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting/ Finance, Recovery, Compliance, Configuration, Network Management, IT Ops, etc.) to enable…