Claims Supervisor

Key Responsibilities

1. Operational Leadership & Performance

• Manage daily adjudication operations ensuring accuracy, productivity, and SLA attainment.

• Oversee team performance through dashboards, scorecards, and KPI monitoring.

• Lead daily/weekly huddles, coaching sessions, and escalations.

• Implement an Attendance and Performance Early Warning system to prevent SLA risks.

• Drive continuous improvement initiatives to reduce errors, processing delays, and rework.

2. Training Program Ownership (End-to-End)

Fully own all training pillars, including:

Curriculum Development & Materials

• Create structured training programs, curriculum, and learning modules for all levels.

• Maintain training documents, guides, SOPs, and reference materials.

Assessments & Certifications

• Develop quizzes, evaluations, certification exams, and progression criteria for adjudicators.

• Manage bootcamps, uptraining, and graduation processes.

Ongoing Training & Reporting

• Conduct refreshers, new-hire training, and remediation programs.

• Provide training progress tracking and reporting to leadership and clients.

3. Quality Assurance Oversight

Own the full QA ecosystem, including:

• Develop/maintain QA guidelines and audit forms.

• Oversee QA review cadence, scoring methodology, and error trend analysis.

• Implement audit-the-auditor processes and calibration sessions to ensure consistency.

• Manage rebuttal processes and error investigations.

• Prepare QA score reports, insights, and root-cause analysis for clients.

4. Accountability & Coaching

• Execute structured coaching, performance reviews, success plans, and PIPs when needed.

• Recognize high performers and manage corrective action for underperformance.

• Build a culture of transparency, ownership, and professional growth.

5. Client Engagement & Reporting

• Serve as the primary operational point-of-contact for client communications.

• Respond rapidly to all client inquiries, escalations, and requests (same hour).

• Deliver weekly & monthly business reviews including:

o Production performance

o Quality scores

o Training updates

o SLA attainment

o Corrective actions and improvement plans

• Ensure all reporting formats are consistent across campaigns and aligned to client expectations.

6. Process & Compliance Management

• Ensure adherence to contract requirements, regulatory standards, and operational controls.

• Maintain updated SOPs and ensure all team members follow defined workflows.

• Partner with internal departments (HR, WFM, QA, Training, Client Services) to align on execution.

Qualifications

Required

• 5+ years of experience in U.S. healthcare claims adjudication, with deep end-to-end process knowledge.

• 2–3 years of leadership experience managing claims adjudication teams (35-50 FTEs).

• Strong understanding of medical terminology, coding (ICD, CPT, HCPCS), plan structures, and benefit rules.

• Excellent verbal and written communication skills; highly responsive and professional with clients.

• Demonstrated ability to create training programs, curriculum, modules, and certification paths.

• Experience managing KPIs and SLAs in a BPO or healthcare operations environment.

• Strong analytical and problem-solving abilities; comfortable with data-driven decision-making.

• Ability to work in a fast-paced environment and manage multiple priorities.

• Experience supporting U.S. health plans or TPAs.

• Exposure to AI-assisted adjudication tools or digital transformation initiatives.

• Background in quality assurance or instructional design.

Work Setup:

• This would be an office-based position

Key Competencies

• Operational Excellence – Drives KPIs, SLAs, quality, timelines.

• Training & Development – Builds world-class training ecosystems.

• Quality Management – Deep expertise in audits, trends, calibrations.

• Client Communication – Clear, timely, professional, solutions-oriented.

• Leadership – Coaches leaders and frontline staff; builds high-performing teams.

• Accountability – Ensures consistent follow-through and ownership.

• Strategic Thinking – Anticipates risks, proposes improvements, aligns stakeholders.