Claims Operations Team Leader

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.

Job Summary:

 The Claims Operations Team Leader is responsible for activities ranging in scope from claims adjudication, mentoring and coaching frontline staff, stepping in to assist in the absence of the Claims Supervisor and troubleshooting complex claims related inquiries. The Team Leader contributes to supporting all Claims Operations staff in meeting individual goals as well as department level metrics and goals.  

Our Investment in You:

·       Full-time remote work

·       Competitive salaries

·       Excellent benefits

Key Functions/Responsibilities:

·       For all lines of business demonstrate expert knowledge and understanding of WellSense member benefits, policies/procedures, provider network, provider set up and contracts issues, processing systems issues, regulations, as well as industry compliance standards for claims adjudication.

·       Serve as a subject matter expert and first line for escalated issues for Claims Adjudicators in the day to day operations of the department. Exercise good judgment and involve the Supervisor or Manager as necessary.

·       Interpret and process complex claims for all physician, facility and specialty areas - CMS 1500 and UB04.

·       Perform peer audits including quality review and new employee mentoring.

·       Assist Claims Supervisors in workload management such as compiling productivity reports, and distributing daily work through Workflow queues.

·       Represent Claims Operations team through attendance of interdepartmental meetings and participation in cross-functional initiatives as needed.

·       Maintain quality and performance levels while coordinating special team projects.

·       Serve as a backup for the Claims Operations Supervisor as needed.

·       Test system changes and operational enhancements and provides feedback on findings.

·       Handle Supervisor calls/issues when necessary, or any complex or difficult service issues to completion.

·       Respond to staff inquiries in a timely, effective and professional manner. Engaged and open to answering questions, a positive role model, and convey a willingness to contribute to the success of their teammates, management team and the Claims department.

·       Identify, address and reports trends to the appropriate leader.

·       Research customer information in response to difficult inquiries including but not limited to authorizations, payments, denials and eligibility.

·       Foster an environment of professionalism and team work and is a front line resource for all team members.

·       Other duties as assigned by department Supervisors and Manager.

Supervision Received:

·       Direct supervision received weekly.

 Qualifications:

 Education Required:

·       Associate’s degree or equivalent combination of education, training, and experience is required

Experience Required:

·       Three or more years’ experience in a managed care claims environment as a claims adjudicator, senior staff member or other equivalent experience required.

Required Licensure, Certification or Conditions of Employment:

·       Successful completion of pre-employment background check

Competencies, Skills, and Attributes:

·       Ability to maintain production level and quality goals.

·       Strong technical, communication, customer service and organizational skills required, along with the ability to maintain professional working relationships with all levels of WellSense staff.

·       Must be flexible and willing to perform all necessary and appropriate duties to ensure the attainment of departmental and organizational goals.

·       Strong working knowledge of medical terminology as well as CPT4, HCPCS and ICD10 coding sets and HIPAA regulations.

·       Ability to work independently with strong attention to detail while identifying claims issues and resolving claims to final adjudication based on established guidelines.

·       Demonstrate working knowledge of IT applications and tools including Facets, Jiva, Onbase, pricing tools, Microsoft Office (Word, Excel, PowerPoint) and an aptitude to learn new programs.

Working Conditions and Physical Effort:

• Ability to work OT during peak periods.
• Regular and reliable attendance is an essential function of the position.
• Work is normally performed in a typical remote home office work environment.

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