Claims Operations Supervisor

WellSense Health Plan; Boston (MA); Remote; USD 85,000 - 120,000; Full time

Job summary

WellSense Health Plan seeks a Claims Operations Supervisor to oversee claims processing staff and ensure compliance with state and federal regulations. This role involves monitoring claims payments, resolving issues, and leading a team to improve operational efficiency. Ideal candidates will have a Bachelor's degree and relevant experience in claims operations.

Benefits

Full-time remote work

Competitive salaries

Excellent benefits

Qualifications

• Bachelor’s Degree or equivalent experience required.
• Two or more years of claims experience required.
• Strong knowledge of claims processing and compliance.

Responsibilities

• Supervises Claims Operations staff responsible for processing claims.
• Monitors claims payment and resolves issues impacting claims.
• Conducts performance appraisals and ensures compliance with standards.

Skills

Process improvement

Communication

Collaboration

Detail-oriented

Education

Bachelor’s Degree

Tools

Microsoft Excel

Job description

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It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary

The Claims Operations Supervisor provides direct supervision of Claims Operations staff responsible for processing claims for all Plan lines of business. The Supervisor ensures that all necessary tools and resources are available to meet or exceed state and federal contractual requirements and Plan internal metrics. The Supervisor is responsible for proactively and methodically identifying and resolving service barriers to initial claims handling and/or data entry productivity and quality.

Our Investment In You

• Full-time remote work
• Competitive salaries
• Excellent benefits
  
  

Key Functions/Responsibilities

• Monitors claims payment post agreement and configuration modification to ensure appropriate payment
• Reviews paid claims data and Quality feedback to identify, analyze and report emerging configuration or agreement issues impacting claims payment.
• Submits Facets questions and configuration requests to Manager to correct identified systemic claims payment issues
• May participate in or supervise and track issue reporting for all claims personnel performing Facets testing.
• Monitors the aging of claims and produces a daily claims inventory report using the BMCHP reporting tool for managerial review.
• Works with Human Resources and Manager on corrective action performance improvement plans and follow-up to ensure positive outcomes
• Supervises claims adjudicators to ensure productivity and quality through ongoing training and setting of professional standards
• Supervises claims mailroom staff, including scanning of paper claims and reconciliation of incoming and outgoing paper claims inventory. Troubleshoots scanning and imaging storage system issues with IT Department and vendor. Escalates unresolved issues to management in a timely fashion.
• Responsible for performance appraisals of all direct reports
• Ensures monthly compliance with corporate standards.
• Works as a member of the Claims Operations management team to ensure appropriate work allocation and adherence to all State and Federal requirements by sharing resources when necessary
• Maintains regular meeting schedule with other claims personnel to review procedures as well as identify and resolve claims issues.
• Maintains current knowledge of BMCHP/Well Sense benefits, provider network development and contract issues, state and federal regulations for all lines of business, BMCHP payment and reimbursement policies and industry standards for claims processing.
• Participates in both internal and external department audit
  
  

Supervision Exercised

• Supervises 10 – 15 staff
  
  

Supervision Received

• Direct supervision is received weekly or as needed
  
  

Qualifications

Education:

• Bachelor’s Degree or the equivalent combination of training and experience is required.
  
  

Experience

• Two or more years Claims experience required
• Two or more years of experience in healthcare or managed care is required
  
  

Preferred/Desirable

• Two or more years supervisory experience preferred, preferably in claims operations.
  
  

Certification Or Conditions Of Employment

• Pre-employment background check
  
  

Competencies, Skills, And Attributes

• Effective collaborative and proven process improvement skills.
• Strong oral and written communication skills; ability to interact within all levels of the organization.
• A strong working knowledge of Microsoft Office products with emphasis on Excel
• Demonstrated ability to successfully plan, organize and manage projects
• Detail oriented, excellent proof reading and editing skills.
  
  

Working Conditions And Physical Effort

• Regular and reliable attendance is an essential function of the position.
• Work is normally performed in a typical interior / remote office work environment.
• No or very limited physical effort required. No or very limited exposure to physical risk.
  
  

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

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Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Contract

Job function

• Job function

  Management and Manufacturing

• Industries

  Hospitals and Health Care, Non-profit Organizations, and Government Administration

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