Supervisor, Claims BPO Operations

Role Overview

• Responsible for the direct supervision of Operations staff, including interviewing, hiring, performance management, time keeping records, training, coaching and employee development.
• Building a cohesive, empowered and productive work environment.
• Responsible for improving production processes and quality on a continuous basis.
• Manage prioritization of system configuration, testing and implementation activities involving claims and encounter data.
• Facilitate the development and execution of user acceptance scenarios and scripts for testing system changes and enhancements.
• Manage claims and billing Clearinghouse (TPA) for Medicaid programs.
• Oversee end‑to‑end claims and billing operations with the TPA for Medicaid programs, ensuring accuracy, efficiency, and alignment with program requirements.
• Provide strategic guidance to providers on claims preparation and submission, including developing training materials and enabling process improvements.
• Ensure timely and compliant submission of all required program documentation, maintaining strong operational controls.
• Lead oversight of clearinghouse claim workflows, including escalation management, technical issue resolution, and root‑cause analysis for provider rejections.
• Drive program compliance and performance through rigorous monitoring, reporting, and continuous improvement initiatives.
• Regularly monitor departmental contractual compliance with state, CMS, OIC requirements (claims benefit configuration, claims timeliness, claim denials, encounter data submissions, clearing house); including supporting the collection and submission of required operational performance metrics and data reporting requirements.
• Provide oversight including SLA reporting and audit to Operations’ assigned vendors.
• Lead the analysis and documentation of business process workflows, policies and procedures for Operations.
• Act as the subject matter expert for Operations in companywide or specific projects, including configuration on vendor systems.
• Monitor the performance of processes within the Operations Department identifying improvement strategies and interventions when targets are not met.
• Lead and guide process owners and internal stakeholders in the planning and execution of process improvement activities including identifying suitable strategies, methodologies and interventions necessary to achieve desired outcomes.
• Take a leadership role working with project teams to develop and track key performance targets and metrics to effectively monitor improvement activities and interventions. Regularly report results to management and project owners.
• Participate in and oversee the work involved in a variety of audits including TEAMonitor, HEDIS, NCQA, CMS, Internal audit.

Requirements

• Bachelor’s degree in health care or an equivalent combination of education and highly equivalent experience required.
• Minimum five (5) years’ managed care/health plan operations experience required.
• Minimum four (4) years’ leadership (supervisory/management) experience in a related field, required.
• Minimum three (3) years’ experience as a Senior Operations Analyst at CHPW, preferred.
• Experience overseeing healthcare claims operations, including benefits administration, system configuration, and implementation of complex provider rates, pricing methodologies, fee schedules, clearing house administration.
• Proven leadership in managing professional and institutional claims within third‑party administration environments, ensuring accuracy, compliance, and operational excellence.
• Background in Medicaid, Medicare, OIC claims administration, benefit interpretation predilection for process improvement, identifying, planning and executing appropriate strategies, methodologies and activities to achieve team and company goals.

Benefits

• Medical, Prescription, Dental, and Vision
• Telehealth app
• Flexible Spending Accounts, Health Savings Accounts
• Basic Life AD&D, Short and Long-Term Disability
• Voluntary Life, Critical Care, and Long-Term Care Insurance
• 401(k) Retirement and generous employer match effective the 1st of the month following or coinciding with the employee’s start date
• Wellness programs (Employee Assistance Program and Mental Fitness app)
• Financial Coaching, Identity Theft Protection
• Paid Time Off (PTO) including PTO accrual starting at 17 days per year
• 40 hours Community Service volunteer time
• 10 standard holidays, 2 floating holidays
• Compassion time off, jury duty
• A monthly stipend to offset work-from-home expenses for roles that are 100% remote