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 to stepping in to assist in the absence of the Claims Supervisor. The Team Leader contributes to supporting all Claims Operations staff in meeting individual goals as well as department level metrics and goals. The Team Leader works closely with the management team, assists in peer review when needed, and responds to claims related customer inquiries. The Team Leader coordinates system testing and troubleshoots complex claims issues in Facets. The Team Leader will meet productivity and quality standards as well as assist teammates in achieving these goals.

The Team Leader mentors, and coaches Claims Operations staff to assist in delivering quality service in claims resolution. The Team Leader fosters an environment of professionalism and team work and is a front line resource for all team members. The Team Leader will encourage and develop a strong working relationship with the Claims staff. 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, a positive role model, and convey a willingness to contribute to the success of their teammates, management team and the Claims department.

Our Investment in You:

• Full-time remote work
• Competitive salaries
• Excellent benefits

Key Functions/Responsibilities:

* Demonstrates expert knowledge and understanding of BMCHP members' benefits, policies/procedures, provider network development and contract issues, processing system issues, Massachusetts Medicaid regulations, as well as industry standards for claims adjudication.

* Serves as a subject matter expert and first line for escalated issues for Claims Adjudicators in the day to day operations of the department. Exercises good judgment and involves the Supervisor or Manager as necessary.

* Interprets and processes complex claims for all physician, facility and specialty areas - CMS 1500 and UB04.

* Performs peer audits including quality review and new employee mentoring.

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

* Attends interdepartmental meetings and participates in cross functional initiatives on behalf of the department when needed.

* Demonstrates working knowledge of software applications including Microsoft Office.

* Maintains quality and performance levels while coordinating special team projects.

* Serves as a backup for the Claims Operations Supervisor as needed.

* Tests system changes and operational enhancements.

* Handles Supervisor calls/issues when necessary, or any complex or difficult service issues to completion.

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

* Other duties as assigned by department Supervisors.

Supervision Received:

• Direct supervision is received weekly.

Qualifications:

Education:

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

Experience:

• Six or more years experience in a managed care claims environment as a claims adjudicator or senior staff member required.

Certification or Conditions of Employment:

• 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 BMCHP 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 ICD9 coding sets and HIPAA regulations.
• Ability to work independently with strong attention to detail while identifying and resolving claims processing problems based on established guidelines.

Working Conditions and Physical Effort:

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