Claims Supervisor - Claims, Adjustments, Eligibility, Member Onboarding & Group Setup

Job Description

Claims Supervisor – Claims, Adjustments, Eligibility, Member Onboarding & Group Setup

Location: CHSI, Bengaluru, India
Reporting to: Senior Supervisor / Manager Operations
Role Level: Supervisor
Experience Required: 10 years (Healthcare Operations)

Role Purpose

As a Claims Supervisor, you will be responsible for supervising and coordinating end‑to‑end healthcare operations across claims processing, claim adjustments, eligibility maintenance, member onboarding, and group setup. You will lead frontline teams to ensure accurate member and group configuration, timely claims adjudication, compliant adjustments, and seamless downstream processing, while meeting SLA, quality, and customer experience targets.

This role plays a critical role in ensuring upstream accuracy (eligibility, onboarding, group setup) and downstream effectiveness (claims and adjustments), minimizing rework, leakage, and member/provider dissatisfaction in a regulated healthcare environment.

Key Responsibilities

1. Operational Supervision

• Supervise daily operations across:
  • Claims processing and adjudication
  • Claim adjustments and reprocessing
  • Eligibility maintenance and updates
  • Member onboarding and coverage activation
  • Group setup, renewals, and benefit configuration
• Allocate work, monitor queues, volumes, and ageing across processes.
• Ensure adherence to SOPs, business rules, benefit structures, and SLAs.
• Proactively identify and address backlogs, errors, and operational risks.
• Coordinate dependencies across upstream and downstream workflows.

2. Quality, Accuracy & Compliance

• Ensure high accuracy in member eligibility, group setup, and benefit configuration to prevent claim errors and rework.
• Monitor claims and adjustments for correct application of benefits, pricing, and policy rules.
• Conduct regular quality checks, audits, and case reviews.
• Identify error trends, perform root‑cause analysis, and drive corrective actions.
• Ensure compliance with healthcare regulations, audit requirements, data privacy standards (HIPAA/GDPR as applicable), and internal controls.

3. People Leadership

• Lead and support a team of Claims Processors, Eligibility Analysts, and Onboarding Specialists (typically 10–20 FTE).
• Set clear performance expectations and provide ongoing coaching and feedback.
• Support new hire onboarding, training, and cross‑skilling across processes.
• Conduct regular performance discussions and contribute to formal reviews.
• Build a culture of accountability, collaboration, quality, and customer focus.

4. Performance Management & Reporting

• Track daily and weekly performance against productivity, SLA, TAT, quality, and adjustment metrics.
• Prepare and share operational dashboards and reports with Senior Supervisors / Managers.
• Monitor rework, adjustment volumes, and upstream error leakage.
• Use data to highlight risks, trends, and improvement opportunities.
• Drive focused action plans to close performance gaps.

5. Process Improvement & Change Support

• Identify opportunities to improve process efficiency, first‑time‑right outcomes, and member experience.
• Participate in process improvement, standardisation, and automation initiatives.
• Support implementation of new products, benefit changes, group renewals, and system enhancements.
• Act as a change champion, ensuring smooth adoption within the team.

6. Stakeholder Collaboration

• Work closely with Quality, Training, Claims, Enrollment, Configuration, Technology, and Onshore Teams.
• Coordinate issue resolution related to eligibility errors, group setup defects, and claim reprocessing.
• Provide timely operational updates, risks, and dependency insights to leadership.

Your Profile

Experience

• 10 years of experience in healthcare operations, with hands‑on exposure to:
  • Claims processing and adjustments
  • Eligibility and enrollment
  • Member onboarding
  • Group setup / benefit configuration
• 1–3 years in a Team Lead or Supervisory role.
• Experience working in high‑volume, SLA‑driven healthcare environments.
• Strong understanding of end‑to‑end healthcare operations and interdependencies.

Skills & Capabilities

• Solid understanding of claims adjudication, benefit interpretation, eligibility rules, and adjustments.
• Working knowledge of group setup, benefit plans, and configuration accuracy.
• Strong analytical and problem‑solving skills.
• Proficiency in Excel and operational reporting tools.
• Ability to manage multiple workflows and competing priorities.
• Clear and effective communication skills.
• Hands‑on experience with healthcare systems and workflow tools.

Behavioural Attributes

• Results‑oriented with strong ownership and attention to detail.
• Quality‑focused with a compliance mindset.
• Calm under pressure and effective in operational issue resolution.
• Collaborative, approachable, and supportive leader.
• Adaptable and open to change with a continuous improvement mindset.
• High integrity and customer‑centric approach.

Key Competencies

• Frontline people leadership
• Operational execution & discipline
• Quality and compliance focus
• Cross‑process coordination
• Data‑driven performance management
• Problem solving & root‑cause analysis
• Stakeholder collaboration
• Change adaptability