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Claims Processing Team Leader
2 months ago
About Us
GuideWell is a prominent healthcare third-party administrator with a rich history of over 30 years in delivering tailored benefit solutions and managing personalized health plans.
Your Role
The Claims Processing Team Leader will oversee a dedicated group of Claims Examiners, ensuring efficient operations in claims management.
Key Responsibilities:
The following duties represent the core responsibilities of this position, with the possibility of additional tasks:
- TEAM MANAGEMENT (70%):
- Act as the subject matter expert and primary resource for all inquiries related to claims processing.
- Responsible for the recruitment of new team members, collaborating with the Talent Acquisition team, conducting interviews, and providing feedback and approvals. Manage the onboarding process for new hires, coordinating with the Talent Development Department for training plans, check-ins, and progress evaluations.
- Monitor and assess claims, open notes, and backlog daily. Prioritize claims processing tasks and make necessary adjustments to meet deadlines and performance standards.
- Evaluate established metrics for the quality and accuracy of processed claims. Collaborate with Internal Audit and auditors to identify metrics and areas for improvement.
- Provide coaching and support to team members, conducting regular one-on-one meetings. Offer recommendations for performance enhancements to Claims Examiners and senior management. Conduct performance evaluations.
- Recognize and reward team members for achieving goals and objectives, fostering a collaborative team environment aligned with the company’s mission and values.
- Work with HR on disciplinary matters and terminations, ensuring compliance with established procedures for fairness.
- Serve as the timekeeper, reviewing time cards and submitting overtime requests for approval. Evaluate and respond to PTO requests based on business needs.
- CLAIMS HANDLING AND ADMINISTRATION (30%):
- Process high-value claims and review complex cases.
- Investigate claims raised by members or clients.
- Assist management with callbacks for members and providers.
- Engage directly with clients and internal teams to resolve issues or concerns.
- Conduct claim testing for benefit modifications, renewals, and new groups.
- Collaborate with IT/Plan Build to address claim benefits issues.
- Update and create benefit grids as required.
- Support SilverSkills with any claim inquiries or audits.
- Minimum of 2 years of relevant experience as a claims examiner or adjudicator within a computerized claims payment system in the healthcare sector.
- At least 1 year of direct supervisory or management experience.
- A related Bachelor’s degree or equivalent work experience.
- Proven judgment and decision-making abilities, with strong analytical thinking skills.
- Ability to learn quickly and manage multiple tasks effectively.
- Strong written and verbal communication skills, including conflict resolution capabilities.
- Experience in processing various types of medical claims.
- Self-motivated with a solid work ethic.
- Ability to maintain positive relationships with clients, providers, and internal staff.
- Proficient in all MS Office applications.
- Familiarity with customized programs for medical CPT coding and the review of surgical procedures.
To support your well-being, we provide a comprehensive benefits package, including:
- Medical, dental, vision, life, and global travel health insurance.
- Income protection benefits, including life insurance and short- and long-term disability programs.
- Leave programs to accommodate personal circumstances.
- Retirement Savings Plan with employer contributions and matching.
- Paid time off, volunteer time off, and recognized holidays.
- Additional voluntary benefits and a robust wellness program.
Physical Demands:
This role primarily involves sedentary work, requiring minimal physical exertion. Occasional travel may be necessary for meetings and events.
GuideWell is an Equal Opportunity/Protected Veteran/Disabled Employer, dedicated to fostering a diverse, inclusive, and equitable workplace for all employees and communities.
