Supervisor Medical Claims Review San Antonio Texas

Opportunities at WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind Caring. Connecting. Growing together.

Under the supervision of the Director, Utilization Management, the supervisor is responsible for the daily operations of the UM coordinators within the department which includes prioritization of prior authorization requests, determination notification to members and providers, meeting regulatory turnaround time, managing incoming calls for appeals, and providing in-network information to member. Daily coordination with Medical Directors, UM Nurses, UM Coordinators, Intake, provider network and various other departments and staff to deliver cost effective, quality of care services to members, in accordance with WellMed's policies and processes. This position provides administrative and leadership support to the team and manages to six or more employees.

Primary Responsibilities:

• Performs daily oversight and coordination of the UM queues and email box to meet established performance metrics
• Oversees inventory related to prior authorization, claims review, and concurrent review inventory and regulatory timeframes
• Supervising all aspects of the inventory and coordination
• Serves as a primary point of contact and provides explanations for members, providers, and internal partners regarding processes, roles and responsibilities within their department
• Receives telephone calls, electronic, and faxed requests from members, providers, health plans, and other departments for questions related to correspondence or appeal coordination
• Identifies appropriate resources to respond to calls, fax, and electronic messages
• Ability to complete work with established procedures and demonstrates proactive solutions to non-standard or complex requests
• Facilitate team staff meetings in order to review and implement processes that allow for smooth and efficient operations
• Review with management individualized reports reflecting daily production and quality in order to accurately measure and monitor predetermined company, department and individual goals
• Applies a team approach to solve complex problems
• Sets priorities for the team to ensure task completion
• Coordinates work activities with other supervisors
• Assists with the hiring and training of new staff as needed
• Applies employee performance management techniques through job-related coaching, training and development activities
• Produces daily, weekly, monthly, and ad hoc UM reports
• Utilizes care management electronic documentation system, claims system, and provider EMR to locate requested information, determine member eligibility, and to assess information
• Works independently and acts as a resource for others by quick reference of standard operating procedures, ability to research regulatory information, and policies and procedures
• Provides user testing for new versions of care management system and for market expansions to ensure smooth transition
• Performs all other related duties as assigned

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• 5+ years of related experience with at least two years in a supervisory capacity
• 1+ years of managed care experience in Utilization Management
• Medical terminology, ICD and CPT knowledge
• Proficiency with Microsoft Office applications

Preferred Qualifications:

• Claims coder certification or equivalent experience
• Medical Assistant (MA) certification

Physical & Mental Requirements:

• Ability to push or pull heavy objects using up to FORMTEXT FFFFFFFF00000000140006005400650078007400340036000000000000000000000000000000000000000000000000000000 pounds of force
• Ability to properly drive and operate a company vehicle

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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