Claims Team Leader

WellSense Health Plan; United States; Remote; USD 60,000 - 80,000; Full time

Job summary

Join WellSense Health Plan as a Claims Operations Team Leader, where you'll oversee claims adjudication, support a growing team, and enhance service quality. This remote role requires strong experience in managed care environments and expertise in claims processing, along with the ability to mentor and guide staff to achieve departmental goals.

Benefits

Full-time remote work

Competitive salaries

Excellent benefits

Qualifications

• Three or more years' experience in a managed care claims environment as a claims adjudicator or senior staff member required
• Strong working knowledge of medical terminology and coding sets including CPT4, HCPCS, and ICD10
• Ability to work independently with strong attention to detail.

Responsibilities

• Responsible for claims adjudication and mentoring Claims Operations staff
• Coordinates system testing and troubleshooting of complex claims issues
• Serves as a subject matter expert for escalated claims issues.

Skills

technical skills

communication skills

customer service skills

organizational skills

problem-solving skills

Education

Associate's degree or equivalent combination of education, training, and experience

Tools

Facets

Microsoft Office

Job description

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.

JobSummary:

The Claims Operations Team Leader is responsible for activities ranging in scope from claimsadjudication to stepping in to assist in the absence of the Claims Supervisor. The Team Leadercontributes to supporting all Claims Operations staff in meeting individual goals as well as departmentlevel metrics and goals. The Team Leader works closely with the management team, assists in peerreviewwhenneeded,andrespondstoclaimsrelatedcustomerinquiries.TheTeamLeadercoordinatessystem testing and troubleshoots complex claims issues in Facets. The Team Leader will meetproductivityandqualitystandardsaswellasassistteammates inachievingthese goals.

The Team Leader supports efforts to train, mentor, and coach Claims Operations staff to assist in delivering quality service inclaims resolution. The Team Leader fosters an environment of professionalism and team work and is afrontlineresourceforallteammembers.TheTeam Leader will encourageanddevelopastrongworking relationship with the Claims staff. TheTeamLeader is responsible for creating an inspiring team environment with open communication. The Team Leader is a subject matter expert in claims processing,benefits, systems, and policies. The Team Leader will be engaged and open to answering questions, apositive role model, and convey a willingness to contribute to the success of their teammates,managementteamandtheClaims department.

Our Investment in You:

*Full-time remote work

*Competitive salaries

*Excellent benefits

KeyFunctions/Responsibilities:

*For all lines of business demonstrates expert knowledge and understanding of WellSense members' benefits,policies/procedures,providernetwork, provider set up andcontractsissues,processingsystems issues, regulations, as well as industry compliance standards for claimsadjudication.

*Servesasasubjectmatterexpertandfirstlineforescalated issuesforClaimsAdjudicatorsintheday to day operations of the department.Exercises good judgment and involves the SupervisororManageras necessary.

*Interprets and processes complex claims for all physician, facility and specialty areas - CMS 1500andUB04.

*Performspeerauditsincluding qualityreviewandnewemployeementoring.

*AssistsClaimsSupervisorsinworkloadmanagementsuchascompilingproductivityreports,anddistributing dailyworkthroughWorkflowqueues.

*Attendsinterdepartmentalmeetingsandparticipatesincrossfunctionalinitiativesonbehalfofthedepartment whenneeded.

*DemonstratesworkingknowledgeofIT applications and toolsincluding Facets, Jiva, Onbase, pricing tools, MicrosoftOffice (Word, Excel, PowerPoint) and an aptitude to learn new programs.

*Maintainsqualityandperformancelevels whilecoordinatingspecialteamprojects.

*ServesasabackupfortheClaimsOperations Supervisorasneeded.

*Testssystem changesandoperationalenhancements and provides feedback on findings.

*HandlesSupervisorcalls/issueswhennecessary,oranycomplexordifficultserviceissuestocompletion.

*Responds to staff inquiries in a timely, effective and professional manner. The Team Leader also identifies, addresses and reports trends to the appropriate leader.

*Researchescustomerinformationinresponsetodifficultinquiriesincludingbutnotlimitedtoauthorizations, payments,denials andeligibility.

*Otherdutiesas assignedbydepartmentSupervisors and Manager.

SupervisionExercised:

*None.

SupervisionReceived:

*Directsupervisionreceivedweekly

Qualifications:

Education:

*Associate'sdegree orequivalentcombinationofeducation,training,andexperienceisrequired

Experience:

*Threeormore years'experienceinamanagedcare claimsenvironmentasaclaimsadjudicatoror seniorstaffmember required.

CertificationorConditionsofEmployment:

*Pre-employmentbackgroundcheck

Competencies,Skills,andAttributes:

*Abilitytomaintain productionleveland qualitygoals.

*Strongtechnical,communication,customerserviceandorganizationalskillsrequired,alongwiththeabilitytomaintainprofessionalworkingrelationshipswithalllevelsof WellSensestaff.

*Mustbeflexibleandwillingtoperformall necessaryandappropriatedutiestoensuretheattainmentofdepartmentaland organizational goals.

*Strongworkingknowledgeofmedicalterminologyas wellasCPT4,HCPCSand ICD10codingsetsandHIPAAregulations.

*Abilitytoworkindependentlywithstrongattentiontodetailwhileidentifying claims issues andresolvingclaims to final adjudication basedonestablishedguidelines.

WorkingConditionsandPhysicalEffort:

*Regularandreliableattendanceis anessentialfunctionoftheposition.

*Abilitytowork OT duringpeakperiods.

*Work isnormallyperformedinaremote office workenvironment.

*Noorverylimitedphysical effortrequired.Noorverylimitedexposureto 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