Claims Team Lead

Evry Health; Town of Texas (WI); Remote; USD 70,000 - 90,000; Full time

Job summary

Evry Health seeks a Team Leader for the Claims team to oversee and enhance the claim adjudication process while ensuring compliance with regulations. This role offers a full benefits package and engages in mentoring and training within a 100% remote work environment, leading a dedicated team focused on high-quality claim management.

Benefits

Full benefits package

401(k) matching

Health insurance

Vision and dental coverage

Disability and life insurance

Qualifications

• Minimum 3 years of claim experience plus 2 years as a team lead.
• Detail-oriented with strong problem-solving skills.
• Certified Coding Specialist (CCS) or Certified Coding Professional (CPC) preferred.

Responsibilities

• Oversee the end-to-end claim adjudication process.
• Train, lead, and mentor team members.
• Audit auto-adjudicated claims for accuracy.

Skills

Communication

Problem Solving

Attention to Detail

Education

High School graduate

Tools

Microsoft Office

SalesForce

Job description

Evry Health is seeking a Team Leader for the Claim team. This is no ordinary claim role. The team leader is responsible for overseeing the end-to-end claim adjudication process. This includes testing claim configuration and benefit set up to review of the claim form, verification of eligibility, verification of coordination of benefits with other insurance carriers and finalizing claim determination based on the health benefits plan. The team lead has responsibility to audit auto-adjudicated claims to ensure claim accuracy. They also ensure that claims are processed in accordance to State and Federal regulations and meet the company’s contractual obligations. The lead is responsible for writing and maintaining the desk top procedures associated with claim adjudication. The lead will research and respond to Provider Disputes and Claim Appeals. This role reports to the VP of Operations.

About Evry Health and Globe Life

We are on a mission to bring humanity to health insurance. Our high-technology health plans expand benefits, increase access and transparency, and feature a personalized, human approach. We strive to ensure members live happier, healthier lives.

Evry Health is the major medical division of Globe Life (NYSE:GL). Globe Life has 16.8 million policies in force, and more than 3,000 corporate employees and 15,000 agents. For more than 45 consecutive years, Globe Life has earned an A (Excellent) rating or higher from A.M. Best Company.

Roles and Responsibilities

• Effectively manages escalations within the department by ensuring appropriate accountability, sense of urgency, communication and follow through to closure.
• Employs active listening skills, demonstrates patience and empathy and can handle difficult situations tactfully, courteously and professionally.
• Trains, leads, and mentors others.
• Develops claim monitoring processes and provides timely feedback to claim specialists.
• Reviews, researches and responds to Provider Disputes and Claim Appeals.
• Creates configuration requirements by interpreting medical policies, schedules of benefits and/or coverage documents.
• Leads the testing efforts including creation of test cases, execution and reporting of results to ensure the system is configured accurately.
• Identifies and communicates defects or claim system issues and works to resolve them.
• Identifies gaps in the training material and works towards closing them.
• Assists in the development of claim key performance indicators (KPIs).
• Monitors and drives individual and team performance against the KPIs.
• Works with internal departments, vendors, business partners, providers, etc to help coordinate problem solving in an effective and timely manner.
• Demonstrates solid understanding of company billing guidelines and can effectively interpret inquiries related to claims and claim payments.
• Assists call center representatives with escalated issues related to claims.
• Ability to effectively excel in a virtual work environment through active participation in team huddles, Supervisor 1:1s, Instant Messaging, or check-ins.

Experience and Skills Desired

• You have a minimum of 3 years of claim experience plus 2 years as a team lead for a commercial insurance payer.
• You have detailed knowledge of medical and insurance industry terminology including CPT/ICD-10, HCPCS and Revenue Codes.
• You are an excellent communicator, both verbally and in writing and can articulate and communicate complex topics to a broad audience.
• You have prior experience building training/reference materials.
• You can perform comfortably in a fast-paced, deadline-oriented work environment.
• You possess strong attention to detail and problem- solving skills with a high level of accuracy.
• You collaborate and support business and operational units such as Call Center, Medical Management and Appeals and Grievance.
• You are proficient in Microsoft Office applications Word, Excel, Outlook OneNote, etc.
• You have experience with claim adjustments, provider disputes and appeals.
• You have prior experience using a CRM, preferably SalesForce.
• Experience in the Texas Commercial Health Insurance space preferred.

Location and Benefits

• We have offices in Dallas, TX, but we work 100% remote.
• Full benefits package including health insurance, 401(k) matching, vision, dental, life, disability, and vacation.

Employment Status

• Full time (W2)

Shifts

• Business hours.

Minimum Required Education

• High School graduate

Experience

• Minimum of 3 years of claim experience plus 2 years as a team lead for a commercial insurance payer.

Licenses and Certifications

• Certified Coding Specialist (CCS) or Certified Coding Professional (CPC) preferred.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Finance and Sales

• Industries

  Insurance

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Inferred from the description for this job

Medical insurance

Vision insurance

401(k)

Disability insurance

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