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Home » Job Board » CA »

Supervisor, Claims (Quality Assurance)

Orange, CA



Job Description:

Supervisor, Claims (Quality Assurance)


Job Description


Department: Claims Administration

Reports to: Manager, Claims

FLSA status: Non-Exempt

Salary Grade: I - $61,000 - $85,000


Job Summary


This position is responsible for ensuring that the Claims Administrations is adhering to regulatory and internal guidelines in conjunction with CalOptima Policies and Procedures, as they apply to claims processing and adjudication. Supervises and oversees the day-to-day operations of the Quality Analyst (QA) staff in the Claims Department. Oversees auditing activities, and processes for CalOptima, including CalOptima Direct and its subcontracted Health Networks for its Medi-Cal, OneCare, OneCare Connect and Program of All-Inclusive Care for the Elderly (PACE) product lines. Interacts with CalOptima management staff, and others as required.


Position Responsibilities:


• Actively engages in Root Cause analysis of deficiencies, and lead efforts in development and implementation of effective remediation and process improvement solutions.

• Conducts regular, ongoing review and analysis of all Claims Quality Assurance Analyst to ensure audit quality and accuracy.

• Trains, audits, and supervises all QA staff to ensure adherence to the Medi-Cal and Medicare processing guidelines.

• Identify any new learning opportunities for staff (i.e., new desktops, Policies and Procedures, etc.) and conducts focused audits as requested.

• Plans, develops, and implement processes, policies, and procedures and other activities to ensure that CalOptima, as well as its subcontracted health networks, are following State and Federal standards and requirements.

• Develops, maintains, updates, or revises all audit tools, scorecards, dashboard, and reporting templates, as necessary.

• Initiates prompt communication with staff. Must schedule monthly unit meetings to go over any changes to programs or training issues; schedule monthly one-on-one meetings with staff to go over their monthly progress regarding their success factors (production, quality, etc.).

• Adjusts staff assignments, direction, and priorities to quickly respond to changing priorities and business needs; ensure flexibility of the department through effective communication of business rationale.

• Monitors and communicates performance goals and results to staff, engaging in appropriate coaching and development opportunities, and improvement action plans as needed.

• Develops and maintains an environment that encourages teamwork and communication and supports quality and process improvement suggestions and solutions.

• Assists with interviewing job applicants and make recommendations for hire.

• Conducts employee counseling/corrective interviews with the assistance of Human Resources.

• Conducts claims presentations as assigned and participates in Delegation Oversight Committee meetings

• Other projects and duties as assigned.


Possesses the Ability To:


• Evaluate and interpret Contracts, Division of Financial Responsibilities (DOFR), Letters of Agreement (LOA).

• Interact with peers face-to-face, over the phone, and in writing in a manner that is professional and productive.

• Coordinate effectively with various departments.

• Effectively supervise, coach, and develop staff.

• Influence others using a positive approach as well as encouraging and utilizing new suggestions and ideas.

• Provide clear, concise instruction to individuals of varying skill levels.

• Plan, organize, and prioritize work, as well as managing and keeping track of multiple tasks.

• Remain objective when dealing with emotional topics or when having to give feedback to staff.

• Establish and maintain effective working relationships with all levels of staff.

• Diffuse emotional situations with employees as well as troubleshooting problem areas.

• Communicate clearly and concisely, both verbally and in writing.

• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.


Experience & Education:


• High school diploma or equivalent is required.

• 4+ years of Medical Health Claims processing experience required.

• 3+ years of experience in a Managed Care environment and interacting with governmental requirements and regulations (Medi-Cal/Medicaid, Medicare) required.

• 2+ years of experience in a supervisory capacity required.

• Experience with interpretation of contracts or LOA's, DOFR's, monitoring, and enforcing contract provisions, payment rates, and quality management required.


Knowledge of:


• Extensive knowledge of ICD-9, ICD-10, Current Procedural Terminology (CPT), and Revenue Codes.

• Solid understanding of the Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS) rules and regulations governing claims adjudication practices and procedures required.

• Principles and techniques of effective supervision.

• Technical area(s) of medical claims administration, including medical terminology, CPT, International Classification of Diseases (ICD-9, ICD-10), codes and Healthcare Common Procedure Coding System (HCPCS) codes.

• Industry pricing methodologies, such as Resources-Based Relative Value Scale (RBRVS), Medicare/Medi-Cal fee schedule, All Patient Refined Diagnosis Related Groups (AP-DRG), Ambulatory Payment Classifications (APC), etc.

• Medi-Cal, Medicare, and Medicaid program guidelines.

• Benefit and contract interpretation and administration.

• Principles and practices of managed care.

• Department reports, their purpose and how to interpret them.

• Department procedures, policies, and expectations.

• Principles and practices of managed health care, and health care systems.

• Effective methods and managing staff and coordinating work.

• Fundamental principles of writing and grammar, including proper report and correspondence format, correct spelling and proper word usage, grammar, punctuation, and sentence structure.


CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.


If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.


Job Location: Orange, California


Position Type:


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07/19/2021 08/18/2021



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