Claims Team Leader

pacificsource; Missouri; Hybrid; USD 65,000 - 90,000; Full time

Job summary

PacificSource in Missouri is seeking a Supervisory Claims Analyst to lead and develop the claims team, ensuring accurate processing and compliant service for members and providers.

You will coach staff, monitor performance, and drive Lean improvements while coordinating with other departments to resolve adjudication issues and maintain high-quality workflows.

Qualifications

• Minimum 3 years of supervisory experience in related insurance field.
• Requires a high school diploma or equivalent.
• Ability to understand PacificSource products, plan designs and health insurance terminology.

Responsibilities

• Provide supervision, coaching, training, evaluation and leadership to assigned staff.
• Oversee claims processing quality to meet department and company standards.
• Resolve claims adjudication issues and coordinate with other departments.
• Coordinate with Training Coordinator on education for staff.
• Communicate changes in processes to team in a timely manner.
• Participate in interdepartmental committees and department meetings.

Skills

Leadership

Supervisory experience

Communication

Claims processing knowledge

HIPAA compliance

Education

High school diploma or equivalent

Tools

Microsoft Word

Excel

Claims processing system

Job description

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care!

PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Supervise and provide leadership and guidance to Claims Analysts and support staff regarding company policies, procedures and workflow Manage claims production and quality that meets or exceeds company standards. Resolve claims adjudication issues. Responsible for hiring, training, coaching, counseling, and evaluating team member performance. Demonstrate effective leadership by coaching to improve individual performance, develop teamwork and team support, manage change and encourage innovation, build collaborative relationships, encourage involvement and initiative, and develop increased vision and commitment to goals in others.

Essential Responsibilities:

• Provide supervision, coaching, training, evaluation and leadership to assigned staff. Assure claims processing, production and quality meet department and company standards.
• Evaluate performance of team members. Analyze results of performance reports for each team member to determine training needs related to personal performance and department goals.
• Oversee and assist team in providing exceptional claims processing service to members, providers, employers, agents and other insurance companies. Includes accurate interpretation of benefit and policy provisions.
• Oversee and assist with review and research of medical and dental claims and determine coverage based on contract, provider status and claims processing guidelines. Investigate and settle claims issues as needed. Relay information for dispute resolution, including research and response for grievances and appeals, to appropriate departments and personnel.
• Communicate changes in business processes and procedures to ensure team members receive information in a timely manner.
• Work collaboratively with department Training Coordinator in all aspects of initial and continued education for assigned staff.
• Oversee and assist with answering inquiries received by mail or e-mail, providing exceptional service. Write original business letters and prepare reports as needed.
• Serve on various interoffice committees as required or needed. Document and report any pertinent communications back to the team and/or department.
• Actively participate in Claims leadership peer group to ensure cross-team communication, collaboration and process efficiency result in consistent, quality claims processing outcomes.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Coordinate business activities by maintaining collaborative partnerships with key departments.
• Assist with process improvement and work with other departments to improve interdepartmental processes. Utilize lean methodologies for continuous improvement. Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.
• Actively participate as a key team member in department meetings.
• Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.

Supporting Responsibilities:

• Actively participate in department or inter-departmental workgroups. Share information or issues with department leaders.
• Regularly attend team meetings and daily team Visual Board huddle.
• Meet department and company performance and attendance expectations.
• Perform other duties as assigned.

Work Experience:

Minimum of 3 years of experience in closely related insurance field or 3 years of supervisory experience required.

Education, Certificates, Licenses:

Requires high school diploma or equivalent.

Knowledge:

Ability to gain a thorough understanding of PacificSource products, plan designs, provider relationships, and health insurance terminology. Basic working knowledge of Oregon Insurance Division rules and regulations. Thorough understanding of claims processing system and operation. Advanced PC skills including, Microsoft Word and Excel. Ability to type using a standard keyboard, operate 10-key pad accurately, multi-line telephone system, and fax machine. Research skills and ability to evaluate claims in order to audit accurately. Advanced skills in medical terminology, C