Manager of Claims

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 Manager of Claims is responsible for managing the operational performance of the claims area to ensure production and quality standards are achieved and are in line with the Plan’s strategic goals.  This includes responding to related interdepartmental requests, and providing analytical and reporting support related to claims operations. The Manager is responsible for developing policies and procedures, workflows, maintaining claim payment quality and identifying training needs for staff. The claims manager will participate with other members of management to discuss, develop and implement operational and organizational processes that improve efficiency.

Our Investment in You:

·       Full-time remote work

·       Competitive salaries

·       Excellent benefits

Key Functions/Responsibilities:

• Responsible for day-to-day management of the Claims Department function.
• Manages staff development, work standards and recruits, motivates and retains a high caliber team to ensure efficient operation of all claims functions.
• Collaborates with training and quality resources to provide on-going training for staff which includes performance coaching.
• Establishes and maintains standards of performance for productivity, quality and claims turnaround. Adjusts such standards when necessary due to processing system enhancements, streamlined workflows or other production efficiencies.
• Provides feedback, suggestions, status updates to department leaders regarding improvement initiatives and opportunities. Provides input into development of the department budget and manages and controls expenses while meeting operations requirements.
• Monitors relevant daily and weekly claims status reports, levels of service, transaction receipts, productivity, and quality to identify performance gaps.  Takes corrective action and follows up to ensure positive outcomes and goals are achieved.
• Develops and documents workflows, business policies, practices and procedures to ensure quality and consistency
• Obtains and maintains a complete understanding of the Facets system
• As appropriate and/or assigned, the Claims Manager is responsible for the preparation and research of data and records as well as associated reports required to meet internal and external audit and regulatory requirements.
• Communicates details and provides examples of provider billing problems, contracting, coding, member and IT issues to the appropriate departments   in a timely fashion and works with these organizations to resolve such issues.
• Identifies, communicates, and escalates issues to the Director of Claims, Enrollment and Provider Appeals on a timely basis.
• Coordinates resources to ensure that projects have sufficient means to meet/exceed expectations. Maintains and attends regular meeting scheduled with other functional departments to identify any processing system issues that negatively impact claims productivity and/or quality, review procedures, and resolve issues.  Ensures that all IT system changes that affect service levels and processing are thoroughly tested before being incorporated into the live environment.
• Maintains current knowledge of provider network development and contract issues, applicable State and Federal policies and regulations, as well as industry standards for claims adjudication issues.  Ensures that these issues are captured in training and reference materials as well as policy & procedure documents.
• Expected to take on and complete any other assignments outside of the regular duties for this position when assigned by management.

Supervision Exercised:

·       Directly/indirectly manages/directs 30-50 employees within Claims Operations.

Supervision Received:

• Direct supervision received weekly.

Qualifications:

Education

·       Bachelor’s degree or the equivalent combination of education, training and relevant work experience, usually 6-7 years related experience in a managed care plan.

Experience Required: 

• Minimum of 5 years of claims operations experience required
• Previous experience supervising/managing staff

Experience Preferred/Desirable:

•  Minimum of 5 years of experience at the supervisor and/or manager level strongly preferred
•  Minimum of 5 years of experience working for a managed care plan preferred
• Facets experience is strongly preferred
• Medicaid and Medicare managed care experience preferred
• Claims billing experience working for a provider is preferred
• Some knowledge of CMS regulations preferred

 Required Licensure, Certification or Conditions of Employment:

·       Successful completion of pre-employment background check

 Competencies, Skills, and Attributes:

•  Detail oriented, organized, and possesses demonstrated leadership skills along with excellent verbal and written communication skills.
• Ability to apply independent and critical thinking to solve complex problems
• Excellent interpersonal skills are required to effectively develop and maintain strong working relationships with internal and external colleagues.
• Proficiency in the use of Microsoft Office products such as Word, Excel, PowerPoint and Outlook required.  Experience with Facets highly desirable.
• Working knowledge of claims processing systems, CPT-4 and ICD-10 coding, and relevant State and Federal regulations
• Excellent organizational skills and attention to detail.

• Ability to multi-task, prioritize and work independently
• Ability to initiate and drive change; demonstrated results-driven approach
• Demonstrated ability to work independently and manage multiple complex projects simultaneously.
• Proactive, motivated, and a collaborative team player.
• Demonstrated ability to adapt quickly to changing priorities.

Working Conditions and Physical Effort

• Ability to work outside of normal business hours as needed.
•  Fast-paced environment.

• Regular and reliable attendance is an essential function of the position.
• Work is normally performed in a typical remote home office work environment.
• No or very limited physical effort required. No or very limited exposure to 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