Title: Claims Regulatory Compliance Supervisor

Location: Fountain Valley, CA

Department: Claims

Status: Full-time

Shift: Days (8hr)

Pay Range*: $30.65/hr - $44.45/hr

MemorialCare is a nonprofit integrated health system that includes four leading hospitals, award-winning medical groups – consisting of over 200 sites of care, and more than 2,000 physicians throughout Orange and Los Angeles Counties. We are committed to increasing access to patient-centric, affordable, and high-quality healthcare; your personal contributions are integral to MemorialCare's recognition as a market leader and innovator in value-based and other care models.

Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration, and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation, and teamwork.

Position Summary

Under minimal supervision and in a professional and friendly manner, performs all assigned job tasks to the highest level of accuracy and timeliness.

The role supports the supervision of Claims Compliance production staff, administrative personnel, and mailroom operations, ensuring efficient receipt and distribution of incoming mail. It requires a strong understanding of outpatient facilities and professional claim processing, including comprehensive knowledge of CPT, HCPCS, ICD-9 coding, and various reimbursement methodologies such as Medicare Fee Schedules, case rates, APC, ASC, and Medi-Cal. The position also demands expertise in interpreting and applying the Division of Financial Responsibility (DOFR) for Managed Care contracts. Additionally, the role contributes to regulatory audit preparation and execution, provides leadership within the unit, prioritizes daily activities, and monitors inventory aging to maintain operational efficiency and compliance.

Essential Functions and Responsibilities of the Job

1. Prepare and maintain compliance inventory reports and manage assignment of work assignments, including exercising authority when appropriate, to allocate resources and direct activities to departmental advantage

2. Prepare and maintain regulatory reports and supporting attestations

3. Assign, manage, and/or handle special projects delegated by manager or senior management and keep the manager informed when problems may interfere with work being completed on time

4. Develop and incorporate quality control measures into the daily work flow

5. Develop and maintain templates, forms, reports, and other tools to assist in monitoring timeliness and payment accuracy and health plan regulatory audit success (let’s modify so it doesn’t sound lie Claims Production management)

6. Coordinate closely with Compliance & Manager on quality performance

7. Prepare and maintain clerical production reports

8. Respond appropriately to team questions and concerns and identify issues for training opportunities

9. Interface with other departments to resolve Compliance issues

10. Develop methodologies for identifying root cause errors that surface through claims audits.Feed this important information to appropriate management staff to assure root cause error resolution (including IS, PNM, UM, Eligibility and Benefits, and internal Claims staff).

11. Participate in quality improvement activities for departmental and unit-specific processes

12. Participate in the training of new employees and offer guidance and assistance to educate staff

13. Participate in reviewing, revising, and developing policies and procedures for the department

14. Complete performance evaluations, coach, counsel and/or discipline employees as necessary to improve performance (this should remain with you but can add provide feedback into )

15. Assist in monitoring time and attendance

16. Assume responsibilities of Claims Regulatory Audit Manager in his/her absence

17. Be at work and be on time

18. Follow company policies, procedures and directives

19. Interact in a positive and constructive manner

20. Prioritize and multitask

*Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities. Health and wellness is our passion at MemorialCare—that includes taking good care of employees and their dependents. We offer high quality health insurance plan options, so you can select the best choice for your family. And there’s more...Check out our MemorialCare Benefits for more information about our Benefits and Rewards.

Minimum Requirements

Qualifications/Work Experience:

At least 5 years claims processing experience

• 3 years claims regulatory audits

• Minimum 2 years supervisory experience

• Knowledge of regulatory requirements: CMS, DMHC

• Strong written and verbal communication skills

• Working knowledge of Microsoft applications – Word, Excel

• Ability to work well with others

• Demonstrates professionalism in appearance and demeanor

• Flexibility in work schedule

Education/Licensure/Certification:

• High School diploma