Claims Team Leader

PacificSource; Oregon (WI); On-site; USD 51,000 - 81,000; Full time

Job summary

PacificSource is seeking a supervising leader for the Claims team to guide analysts and support staff in processing claims accurately and efficiently. You will ensure adherence to policies, HIPAA regulations, and performance standards while driving coaching, training and development efforts.

The role emphasizes teamwork, continuous improvement, and cross‑department collaboration to deliver exceptional service to members, providers and employers.

Qualifications

• Minimum of 3 years of experience in a related insurance field or 3 years of supervisory experience.
• High school diploma or equivalent required.
• Thorough knowledge of PacificSource products, HIPAA rules and claims processing.

Responsibilities

• Supervise and lead Claims Analysts and staff to ensure policy and workflow compliance.
• Oversee claims production and quality, resolve adjudication issues, and drive performance.
• Hire, train, coach and evaluate team members to improve performance.
• Interpret benefits and policy provisions for accurate claims processing.
• Coordinate with departments and committees to improve processes and outcomes.

Skills

Accountable leadership

Team management

Communication

Critical Thinking

Decision Making

Organizational skills

Collaboration

Education

High school diploma or equivalent

Tools

Microsoft Word

Excel

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, CPT / ICD-10 coding. Effective and responsive leader. Current knowledge of changes in PacificSource business processes and procedures and relating that information to team members. Ability to work under time pressures and deal with difficult situations. Team player. Collaborates with others and helps to accomplish objectives. Strong work ethic and ability to work effectively with a variety of personalities at varying skill levels.

Competencies:

• Building Trust
• Building a Successful Team
• Aligning Performance for Success
• Building Customer Loyalty
• Building Strategic Work Relationships
• Continuous Improvement
• Decision Making
• Facilitating Change
• Leveraging Diversity
• Driving for Results

Environment:

Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

Skills:

Accountable leadership, Collaboration, Communication (written/verbal), Critical Thinking, Decision Making, Influencing, Listening (active), Organizational skills/Planning and Organization

Compensation Disclaimer

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

Base Range:

$50,830.78 - $81,329.23

Our Values

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements

Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer:

This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.