DUTIES AND RESPONSIBILITIES
The essential functions include, but are not limited to the following
Monitor and manage team performance against established KPIs, productivity goals, quality standards, and turnaround time expectations.
Oversee inventory management, backlog reduction efforts, and aging claim performance to ensure claims are processed within established service standards.
Monitor workload distribution and prioritize resources to maintain inventory levels and minimize aged claims.
Partner with the CSS Team Lead to address year-end processing activities, aging inventories, claim status inquiries, and cross-departmental workflow issues.
Provide day-to-day leadership, training, coaching, and guidance to Claims Processors.
Generate and analyze claims processing, inventory, productivity, quality, and auto-adjudication reports and communicate trends to management.
Monitor auto-adjudication outcomes and work closely with Plan Builders to identify issues, provide feedback, and support resolution through implementation.
Serve as an escalation point for complex claims, claim inventory concerns, and operational questions.
Identify process improvement opportunities that increase efficiency, reduce inventory, and improve claim turnaround times.
Ensure compliance with plan provisions, departmental procedures, and company policies.
Partner with management to communicate team performance, operational challenges, and opportunities for improvement.
Other job duties include, but are not limited to the following
May perform other duties as required.
MINIMUM QUALIFICATIONS (KNOWLEDGE, SKILLS, AND ABILITIES)
Associate's or Bachelor's degree preferred. Relevant experience in claims processing, insurance operations, healthcare administration, benefit administration, or related responsibilities will be considered in lieu of a degree.
3+ years of progressive experience in healthcare, insurance, client services, claims operations, or a related field, with one year of leadership experience in a supervisory or team lead capacity.
Strong knowledge of claims adjudication, benefit structures, accumulators, and Coordination of Benefits (COB) required.
Experience managing claim inventory, backlog reduction initiatives, and aging claim performance.
Ability to analyze operational data, identify trends, and implement effective solutions.
Strong verbal and written communication skills.
Excellent organizational, prioritization, and time management abilities.
Proficiency in Microsoft Office applications, particularly Excel and reporting tools.
Ability to build effective working relationships with processors, management, Plan Builders, the CSS Team Lead, and other internal business partners.
OTHER DETAILS
Supervisory Responsibilities
Direct supervision of the Claims Processing team
Work Environment
The noise level in the work environment is usually low to moderate.
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions. While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers, handle or feel objects, tools, or controls. The employee is occasionally required to stand; walk; sit; and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, and the ability to adjust focus.
Travel Requirements
None
NOTE
This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise.
The Company complies with employment regulations as they apply to the location of service.
