Supervisor, Claims

Position Summary

The Supervisor, Claims provides daily leadership and supervision to a Claims team in accordance with Company guidelines, client needs, and regulatory requirements.

"Has minimum necessary access to Protected Health Information (PHI) and Personally Identifiable Information (PII) by Job Description/Role."

Key Duties and Responsibilities


* Provides daily leadership and supervision to staff consistent with Company values and mission.


* Assigns, distributes, and monitors quality and quantity of work produced, ensuring employees are held accountable for consistently meeting quality and production requirements.


* Develops staff through performance management, goal setting, training, and effective employee relations.


* Maintains current knowledge of assigned Plan(s) and effectively applies knowledge; provides oversight of processing activities to ensure compliance.


* Optimizes workflows/processes, tools, and staff allocation to ensure efficient and cost-effective day to day operations.


* Troubleshoots customer/client service issues and assists in the successful implementation of new clients.


* Reviews and interprets new benefits plans or changes/updates to existing plans; tests benefits for validation and accuracy.

Develops and distributes resource documents as needed.


* Based on location needs, may provide advanced technical review and support of claims processing.
+ Provide technical review of all types of claims including large dollar and complex claims to validate benefit allowance and category.
+ Investigate, evaluate, and report on advanced cases for third-party recovery including stop-loss, accident, medical malpractice, subrogation, and Worker's Compensation.


* Compiles documents, records, and data for external audits, as requested.


* Assists in the development and documentation of departmental SOP's.


* Performs other duties as assigned.

Minimum Qualifications


* High school diploma or GED.


* Four years of experience processing complex health and welfare claims in a third-party administrator.


* One year of experience in a lead or supervisory role.


* Advanced knowledge of benefits claims adjudication principles and procedures and medical and/or dental terminology and ICD-10 and CPT-4 codes.


* Thorough knowledge of claims operations to include payment of claims, interpretation of contracts, communication of benefits, etc.


* Exceptional team player with the confidence and integrity to earn client and internal team confidence quickly.


* Highly developed sense of integrity and commitment to customer satisfaction.


* Ability to communicate clearly and professionally, both verbally and in writing.


* Strong decision-making and organizational skills, with the ability to optimize the use of all available resources and deliver on multiple priorities.


* Exceptional analytical and problem resolution skills; ability ...