Claims Audit and Dispute Supervisor

Kern Family Health Care•Bakersfield, CA

7d•Onsite

About The Position

Under the supervision of the Claims Administrative Manager, the Claims Audit and Dispute Supervisor will follow organization policies and KHS guidelines; and is responsible for supervising the functions of the day-to-day processing of auditing and claims dispute resolution, ensuring the timeliness and accuracy of claims payments and regulatory adherence.This position is responsible for supervising the claims dispute resolution process and the internal claims audit function for a Knox-Keene licensed health maintenance organization (HMO).

Requirements

Bachelor's degree in business administration or related field from an accredited institution or equivalent AND 6 years of administrative experience in a medical claim’s payment processing operation. 2 of 6 years must be supervisory or lead or senior level Claims payment processing position.
OR 8 years’ experience in medical claims payment processing operation. 2 of 8 years must be supervisory or lead/senior level Claims payment processing, auditing or claims dispute position.

Nice To Haves

Health maintenance organization (HMO) claims payment-processing experience is highly desirable.

Responsibilities

Supervise, train, and mentor staff.
Monitor team productivity, quality, and turnaround times.
Conduct regular performance evaluations and coaching sessions.
Develop and implement training programs on dispute resolution processes and regulatory updates.
Oversee the review, investigation, and resolution of Disputes
Ensure appeals and reconsiderations are submitted accurately and within required timelines.
Review high-dollar, high-risk, or escalated claims disputes.
Identify trends in disputes and recommend corrective actions.
Ensure all dispute processes comply with state guidelines, payer contracts, and federal/state regulations.
Maintain up-to-date knowledge of healthcare reimbursement policies.
Assist in internal and external audits related to claims disputes.
Analyze denial data and develop strategies to reduce recurring issues.
Prepare and present performance reports (KPIs such as denial rates, appeal success rates, aging).
Recommend system enhancements or workflow improvements.
Serve as escalation point for complex payer communications.
Oversee the selection methodology and percentage of claims pulled for adjudicator audits.
Ensure audits are conducted consistently across all claim types (professional, facility, contracted, and non-contracted provider claims).
Review and validate auditor findings for accuracy, fairness, and scoring consistency.
Conduct routine calibration sessions to ensure alignment in audit standards.
Perform secondary reviews or spot audits as necessary to maintain audit integrity.
Assign workloads and monitor productivity and quality metrics.
Provide coaching and guidance on complex claim determinations and error classifications.
Partner with Claims Supervisors to support adjudicator improvement initiatives.
Identify auditor training needs and coordinate skill development.
Oversee detection and validation of claims processing error trends.
Analyze aggregated audit results to identify systemic issues and root causes.
Prepare and present monthly and quarterly audit reports to Claims Management.
Track accuracy rates and monitor improvement over time.
Ensure error trends are translated into actionable recommendations.
Collaborate with MIS/IT to enhance audit tracking tools and reporting functionality.
Recommend improvements to audit workflows and documentation standards.
Support internal audit reviews related to claims accuracy metrics.
Ensure audit tools reflect current policies, coding updates, and system enhancements.
Ensure audit practices align with established claims adjudication guidelines and HMO regulatory requirements under Knox-Keene.
Maintain productivity and quality standards for the audit unit.
Adhere to all company policies and procedures.
Assist Director of Claims, Deputy Director of Claims, and Manager of Claims in completing claims related special projects.
Perform Other job-related duties as required