Senior Claims Operations Lead

Wellcove; Pensacola (FL); On-site; USD 55,000 - 75,000; Full time

Job summary

Wellcove Pensacola is seeking a Process Leader to guide a claims team and ensure efficient, accurate processing and timely delivery of results. You will mentor staff, coordinate with the Claims Manager, and promote continuous improvement across operational activities.

The role requires strong knowledge of insurance terminology, medical terminology, and coding practices, plus the ability to communicate with clients and internal teams, to uphold service quality and customer satisfaction.

Qualifications

• Must have advanced product knowledge and comprehensive understanding of insurance terminology.
• Must have knowledge of medical terminology and ability to read/interpret medical records.
• Familiarity with medical claim forms (HCFA-1500, UB04) and coding systems (ICD-9/10, CPT/HCPC/CDT).

Responsibilities

• Direct and coach a team to ensure efficient claim processing and timely delivery of business deliverables.
• Monitor operational activities of claim examiners to ensure accuracy and timeliness.
• Provide technical support, expert advice, and coaching to staff and clients.
• Identify opportunities to improve operational effectiveness and customer satisfaction.
• Identify skill gaps and arrange staff training to close gaps.
• Monitor KRAS, KPIS, SLA, AHT, Occupancy, Attrition, Shrinkage and manage team conflicts.
• Handle complaints, DOI, Appeal processes and client conversations.
• Draft process documentation including SOPs and issue trackers; perform quality audits.
• Speak with clients about process-related issues as needed.

Skills

Advanced product knowledge

Insurance terminology

Medical terminology

ICD-9/10 CPT/HCPC

Healthcare knowledge

Education

Certificate/degree from college or technical school

Job description

Job Summary

A process leader leads, monitors, and administrates a group of employees to achieve goals that contribute to the organization's growth. Process leaders motivate and inspire their team by creating an environment that promotes positive communication, encourages bonding of team members, and demonstrates flexibility.

Responsibilities

Working with the Claims Manager, provides daily direction and communication to employees so that the business deliverables are intact, efficient, and knowledgeable manner.

- Monitoring operational activities of claim examiners to ensure claims are processed accurately and timely.
- Provide technical support, expert advice, and coaching assistance to team members and clients.

- Identify new opportunities to improve operational effectiveness and customer satisfaction and make recommendations for improvements.
- Identify skill gaps and ensure training is provided to further develop staff.
- Should be aware of KRAS, KPIS, SLA, AHT, Occupancy, Attrition, Shrinkage.
- Should be able to manage team conflict and any people related issue
- Should have experience and able to handle complaints, DOI, Appeal etc.
- Adhere to process reporting, able to draft process documents, including SOP, Update tracker, issue logsetc.
- Ability to do quality audit for team process
- Ability to speak to client on process related issues and able to handle the calls with client

Qualifications
-To perform this job successfully, the individual must be able to perform each essential duty effectively.

- The individual must possess advance product knowledge, comprehensive understanding of insurance terminology and definitions, core knowledge of company and department processes and procedures related to the ability to complete job responsibilities /duties in a proficient and professional manner.

- Must have knowledge of medical terminology, ability to read and interpret most medical records/notes, ICD-9/10 and CPT/HCPC/CDT coding; Familiarity with different medical claim forms, i.e. HCFA-1500 and UB04 forms; working knowledge of Insurance Industry and/or Healthcare.

Education -Experience
One to Two years certificate/degree from college or technical school; or 2-5 years related experience and/or training; or equivalent combination of education and experience.

Language SkillsMust have the ability to read and interpret documents such as policies and operating and procedural manuals; Ability to write routine correspondence; Ability to speak effectively to customers, clients or employees of the organization.
Competencies
Critical Thinking; Customer Service; Work Standards; Decision-Making; Communication; Interpersonal Skills; Integrity/Honesty and Adaptability/Flexibility
Mathematical Skills
Must have the ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals; Ability to calculate figures and amounts such as discounts, interest, and percentages.

Reasoning Ability
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form;Ability to deal with problems involving several concrete variables in standardized situations.