Supervise and provide leadership and guidance to Claims Analysts and support staff regarding company policies, procedures and workflow applicable to Medicare clients. 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.
Provide supervision, coaching, training, evaluation and leadership to assigned staff. Assure Medicare 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, , agents and other insurance companies. Includes accurate interpretation of benefit and policy provisions for Medicare medical policies.
Oversee and assist with review and research of medical 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.
Coordinate business activities by maintaining collaborative partnerships with key departments.
Assist with hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.
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.
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 four years claims adjudication experience and qualified to take on leadership responsibilities, or equivalent experience in a related health field.
Education, Certificates, Licenses: Requires high school diploma or equivalent.
Knowledge: . Thorough understanding of PacificSource products, plan designs, provider relationships and health insurance terminology. Basic working knowledge of Medicare 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.
Building a Successful Team
Aligning Performance for Success
Building Strategic Work Relationships
Driving for Results
Building Customer Loyalty
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 encourage creativity, innovation, and the pursuit of excellence.
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.
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.
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.
PacificSource is an equal opportunity and affirmative action employer.
PacificSource Health Plans is anything but a typical health plan. We’re a growing, independent, not-for-profit organization with a...