Claims Adjudication Supervisor

The Claims Adjudication Supervisor leads day-to-day healthcare payer claims operations and a team of Claims Processors, Claims Examiners, and Senior Associates. The role is accountable for accurate and timely claim outcomes, disciplined inventory management, associate coaching, compliance, and achievement of client-defined productivity, quality, turnaround-time, and service-level expectations.

Key Responsibilities

• Supervise daily claims adjudication activities, work allocation, queue management, attendance, and operational coverage.
• Lead and coach a team of approximately 15-20 claims professionals, with the final span determined by process complexity and the approved operating model.
• Monitor productivity, quality, turnaround time, backlog, aging, pends, rework, and priority inventory; initiate timely recovery actions where required.
• Ensure accurate application of member eligibility, plan benefits, provider information, authorization and referral rules, coordination of benefits, pricing, coding logic, edits, and payer-specific procedures.
• Review and facilitate resolution of complex or escalated claims, including high-dollar claims, adjustments, duplicate claims, provider disputes, reimbursement exceptions, and Medicare or Medicaid scenarios within defined authority.
• Conduct daily huddles, one-to-one coaching, performance discussions, quality feedback, and refresher interventions.
• Partner with Quality, Training, Workforce Management, SMEs, Technology, and Client teams to improve outcomes and sustain operational readiness.
• Lead root cause analysis and corrective or preventive action plans for recurring errors, SLA misses, and control gaps.
• Maintain complete operational records, claim notes, audit evidence, issue logs, and status reporting.
• Support change implementation, new benefit or policy updates, system releases, and transition or ramp activities.
• Promote a culture of ethics, inclusion, accountability, data privacy, and continuous improvement.

Required Qualifications

• Bachelor's degree preferred, or an equivalent combination of education and relevant experience.
• Five or more years of US healthcare payer claims processing or adjudication experience, including at least two years in a team lead or supervisory capacity.
• Working experience with Commercial, Medicare Advantage, Medicaid, managed care, or employer-sponsored health plan claims.
• Strong understanding of the end-to-end claims lifecycle, benefits, eligibility, provider data, authorization and referrals, denials, pends, adjustments, coordination of benefits, and reimbursement concepts.
• Working knowledge of ICD-10, CPT, and HCPCS code sets and their use in claims operations; this role does not require clinical coding unless specified by the account.
• Experience using a payer claims platform such as Facets, QNXT, HealthRules, NASCO, Amisys, or an equivalent enterprise claims system.
• Demonstrated ability to manage production commitments while maintaining accuracy, compliance, documentation, and employee engagement.
• Strong written and verbal communication, analytical problem-solving, stakeholder management, and coaching skills.
• Ability to work from the Cincinnati area and support client-defined business hours, including schedule flexibility during transitions or peak periods.