Claims Supervisor

Triple-S; Guaynabo (PR); On-site; USD 65,000 - 90,000; Full time

Job summary

Triple-S is seeking a Claims Supervisor to oversee claims processing operations in Puerto Rico. The role focuses on ensuring adherence to standards, policies, and regulatory guidelines while leading a team for efficient performance.

The ideal candidate will have a Bachelor’s degree and 3–5 years of experience in health insurance claims processing, with strong analytical and leadership skills to drive process improvements and compliance.

Qualifications

• Bachelor's degree in natural science, arts, or business administration.
• Three to five years of claims processing experience in health insurance.
• Experience in analysis, auditing or risk management preferred.

Responsibilities

• Supervise daily operations and monitor workflow.
• Train, mentor, and oversee staff.
• Monitor performance metrics and ensure timely outputs.
• Collaborate with teams to implement policy changes.
• Prepare productivity reports and presentations.
• Ensure compliance with regulations and company policies.
• Manage claims processing and escalations.
• Communicate trends to improve claims processing accuracy.

Skills

Financial & Business Acumen

Data Driven Insights

Customer Delight

One Company Mindset

Develops Talent

Practical Knowledge in Tech

Education

Bachelor's Degree in Natural Science or Arts

Job description

At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.

When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.

Job Summary

The Claims Supervisor performs activities to ensure claims related processes are executed according to standards, policies, procedures, regulations, laws, and guidelines.

Essential Functions

• Supervise daily operations and processes within the department by monitoring workflow and inventory, including distribution of work.
• Train, mentor, motivate, support, and oversee staff.
• Monitor departmental and individual performance metrics and take proactive action, when necessary, on a timely basis to maintain desired workflow outputs.
• Monitor vendor performance metrics and take proactive action, on a timely basis to maintain desired workflow outputs, when applicable.
• Develop and implement workflow changes to improve service and production efficiency of the department; this may include collaboration with other teams.
• Collaborate with other teams to implement new and revised policies and procedures, which may include suggested system changes or enhancements.
• Partner with internal and external contacts to achieve effective communications and maximum efficiency.
• May act as a liaison in monitoring and supporting specific topic or departmental assignments through reporting and relationship building.
• Select, develop, and evaluate staff to ensure the efficient operation of department.
• Demonstrate Company's Core Competencies and values held within.
• Participate in internal and external audits (i.e but not limited to Compliance, CMS, ASES, SOX, MTM, etc.)
• Stay up to date on local, state, and federal changes in regulations and laws to anticipate impact, new requirements, and potential changes in operational processes.
• Ensure legal compliance by following company policies, procedures, and guidelines as mandated by state and federal legislation and, or health plan or company directives. Alert non-compliance issues, coordinate and manage corrective action plans
• Oversight and, or act as SME on projects, initiatives and, or issues impacting claims operations and contribute with knowledge and experience. Research claim processing problems and errors to determine their origin and appropriate resolution.
• Manage and review complex and, or difficult claims or issues to determine best outcome.
• Prepares, maintain, and monitor productivity reports and presentations as required by management.
• Oversight all claims dependencies delegated to the different operational areas until full resolution to ensure the resolution of any incoming inquiries related to claims processes.
• Supervise and monitor the creation and submission of regulatory reports to ensure the compliance in a correct and timely manner and comply with metrics.
• Communicate with management regarding trends to improve claims processing accuracy.
• Document business rules for incorporation into training programs and assist with the training of new employee and vendor staff.

Education

• Bachelor's Degree in Natural Science or Arts

Experience

Bachelor’s Degree (BD) in Natural Science, Arts or Business Administration preferable with three (3) to five (5) years of experience in the Claims processing preferable in a health insurance industry analysis, investigation, auditing and/or risk management in a Healthcare setting.

LICENSES AND CERTIFICATIONS

• None required

Competencies

• Financial & Business Acumen
• Data Driven Insights
• Customer Delight
• One Company Mindset
• Develops Talent
• Practical Knowledge in Tech

It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.

Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.

We encourage Veterans and Disabled to Apply.