Claims Clerk Supervisor

Job Description

Job Description

The Claims Clerk Supervisor leads the daily clerical and claims-support operations of the Claims department, guiding a team of claims clerks through intake, imaging, data entry, adjustment, correspondence, and appeals-support workflows. Working under the Manager of Claims Operations, this role serves as a subject-matter expert on claims reprocessing and clerical procedures, drives quality and payment accuracy, and supports internal audits and compliance readiness.

The position operates in a modern, largely paperless claims environment built on electronic claim intake (EDI 837), electronic remittance (835), clearinghouse and health-plan portals, and digital document management. The Supervisor is expected to be comfortable adopting and working alongside AI-based and automation tools — such as intelligent document processing (OCR/indexing), auto-adjudication and exception-queue routing, and AI assistants that help draft correspondence, summarize claim and appeal history, and flag anomalies — while exercising sound judgment, validating tool output, and safeguarding protected health information (PHI) in accordance with HIPAA and company policy.

ESSENTIAL RESPONSIBILITIES & DUTIES

Team Leadership & Supervision

• Supervise, train, and mentor claims clerks; serve as the subject-matter expert on claims reprocessing and daily clerical procedures.
• Assign and balance daily workloads, monitor productivity and turnaround times, and ensure end-of-day close-out (batch cover sheets, log sheets, and the end-of-day email) is completed accurately.
• Communicate effectively with the Claims Manager and production staff, and coordinate with client services, external vendors, health plans, and other organizations to resolve claims issues.

Claims Intake, Batching & Document Imaging

• Oversee claims batching, filing of data-entered claims, and daily retrieval of health-plan files (e.g., pulling claims from the Humana SFTP/FTP and health-plan portals).
• Manage document imaging in OnBase and the Mail Room Scan Folder, including separation and scanning of multiple medical records (Mult MR), and use of OCR/intelligent document processing to index and route images for processing.
• Administer fax intake and distribution (RingCentral, fax folders) and ensure all source documents are captured and stored for adjudication.

Claims Data Entry & Adjudication Support

• Perform and supervise data entry of CMS-1500 (HCFA) and UB-04 (UC) claims into EZ-CAP, and process corrected claims (MEDRVW) to meet turnaround-time standards.
• Apply adjustment codes, process copay reversals, resolve invalid billing formats / rejected claims and invalid NDCs, and correctly distinguish first-time claims from adjustments (e.g., Anaheim Global MEC vs. first-time claim).
• Work assigned queues and status codes (e.g., UDUNC, 252, 16), apply PS note codes accurately, and generate member/provider notices using the EOB Writer.

Appeals, Grievances & Provider Disputes

• Support the appeals and grievance (A&G) process: intake of paper and electronic appeals, maintenance of the Appeals Data Entry Log, and pairing appeals with the associated claim image.
• Forward Provider Dispute Resolutions (PDRs) appropriately (requires working knowledge of the PDR process) and respond to Health Plan Demand Inquiries.
• Prepare and track development correspondence — 1st and 2nd request letters for developed claims (mailed and email requests) and forwarding of letters for claims denied under B11.

Eligibility & Provider/Facility Data

• Perform eligibility look-ups and submit eligibility verification requests to confirm coverage prior to adjudication.
• Submit and follow up on provider and hospital add requests to keep provider and facility data accurate.

Quality, Auditing & Compliance

• Audit claims-processing quality; develop, maintain, and run standard and ad-hoc reports to identify root causes and improvement opportunities.
• Support the claims compliance team in preparing for internal and external audits; research and document special conditions or additional requirements affecting adjudication.
• Monitor paper claims submitted and reconcile intake against system totals.

Technology, AI Tools & Continuous Improvement

• Use standardized processes, tools, templates, and productivity software (Microsoft 365, Teams) to manage projects, timelines, and issue tracking; submit and follow up on Help Desk tickets.
• Adopt and champion AI-based and automation tools that improve speed and accuracy — always reviewing and validating AI-generated output before it is relied upon, and never entering PHI into non-approved tools.
• Participate in special claims projects (including STAR/annual-wellness claim processing) and recommend workflow improvements.
• Perform other duties as assigned.

EDUCATION & EXPERIENCE REQUIREMENTS

• High school diploma or GED required; associate’s degree (or equivalent coursework) in healthcare administration, business, or a related field preferred.
• Four to six years of healthcare claims processing / claims operations experience, including at least one to two years in a lead, senior, or supervisory capacity.
• Working knowledge of Medicare, Medicaid, and Commercial claims-processing guidelines; managed-care / IPA or delegated-claims experience preferred.
• Proficiency with CPT, HCPCS, ICD-10-CM coding and RBRVS methodology; a coding credential (e.g., CPC, CCS) is a plus. Revenue-recovery experience is a plus.
• Experience with a claims administration platform such as EZ-CAP and a document-management/imaging system such as OnBase (Hyland) is strongly preferred.
• Comfortable learning and using AI-assisted and automation tools in a claims setting, with good judgment about validating output and protecting PHI.

KNOWLEDGE, SKILLS & ABILITIES

• Strong knowledge of claims-processing rules, guidelines, and clerical workflows; high accuracy and attention to detail.
• Highly organized, able to prioritize and perform multiple tasks efficiently in a fast-paced, deadline-driven environment.
• Computer literate and quick to learn new systems; proficient with Microsoft 365 (Outlook, Excel, Teams), electronic fax, SFTP/portals, and document imaging.
• Clear written and verbal communication; able to work effectively with all levels of staff, providers, and health plans.
• Sound judgment handling PHI; commitment to HIPAA compliance and data security.

AMM BENEFITS

When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:

• Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.
• Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.
• Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
• Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.
• Career Development: Tuition reimbursement to support your education and growth.
• Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun!