Jamaica Plain, Massachusetts
Nashville, Tennessee
Durham, North Carolina
Durham, North Carolina
Durham, North Carolina
Prescott, Arizona
Farmington, Missouri
Augusta, Georgia
Posted: 05-Jun-26
Location: Los Angeles, California
Internal Number: 152334652
The Claims Resolution and Reconciliation Supervisor oversees daily claims resolution operations, ensuring timely, accurate, and compliant processing of complex claims adjustments, provider disputes, appeals, and grievances. This role provides direct supervision to staff, supports operational performance, and ensures compliance with Department of Managed Health Care (DMHC) and Centers for Medicare & Medicaid Services (CMS) requirements, industry standards, and organizational standards.
Key Responsibilities
- Supervise Claims Adjustment Specialists and Provider Dispute Resolution Analysts, including workload distribution, training, coaching, and performance management.
- Oversee daily claims operations to ensure accurate and timely resolution of complex claims adjustments, disputes, and escalated issues.
- Monitor productivity, quality, and inventory metrics to support operational goals and identify trends or areas for improvement.
- Ensure compliance with CMS, DMHC, and internal claims processing policies and procedures.
- Review and approve complex or high-dollar claims within established authority levels.
- Develop and maintain operational reports, workflows, desk procedures, and supporting documentation.
- Support audits, system testing, and implementation activities related to claims operations.
- Collaborate with cross-functional teams to resolve systemic claims issues and improve operational efficiency.
- Bachelor’s degree in Business Administration, Healthcare Administration, or related field, and/or equivalent combination of education and experience.
- Minimum 5 or more years of related experience or training in medical claims processing within a managed care or health plan environment
- Minimum of 2 or more years of experience supervising or leading claims processing staff
- Applies knowledge of revenue cycle operations, claims adjudication, and reimbursement methodologies
- Interprets and applies DMHC and CMS Medicare Advantage regulatory requirements
- Monitors productivity, quality, and inventory metrics to support unit performance
- Provides guidance on complex claims adjustments and provider dispute resolution
- Utilizes claims systems and reporting tools to support operational oversight
- Communicates effectively with staff, leadership, and internal stakeholders
- Manages competing priorities in a high-volume operational environment
- Supports audit activities and regulatory inquiries related to claims processing
- Experience training, mentoring, and coaching staff
- Proficiency with claims processing systems and standard office applications
