Claims Supervisor

Responsibilities

• Demonstrates knowledge and understanding of benefit administration for self-funded healthcare plans
• Ensures that claims are processed and paid in accordance with benefit plans, pricing agreements, and required authorizations
• Manages the inventory of claims against standard service level agreements (SLA’s)
• Edits and mentors claims staff to ensure proper application of client benefit plans to claims processed, at the required quality and production metrics, including establishing performance plans for those falling below expectations with appropriate coaching and mentoring to achieve improvement
• Provides reports to department leaders on claim inventory, production, turn-around lag, and quality metrics
• Develops policy and procedures to ensure that benefit plans and claim standards are properly administered; assists in developing policies and procedures for operations, and monitors claim staff for compliance
• Accountable for positively influencing the morale of the department employees, including setting achievable goals, fostering teamwork by involving team in the design/implementation of solutions to problems
• Responsible to establish annual goals for staff that align with organization strategies and personal growth and can provide timely and constructive feedback on performance
• Affordability: Oversees appeals, subrogation, and overpayment/refunds, ensuring compliance and efficiency

Qualifications

• Required Skills and Abilities: Knowledge: Thorough understanding of insurance policies, claims handling processes, and legal requirements associated with claims. Leadership: Strong leadership and team management skills, with the ability to effectively manage and motivate a team. Analytical Skills: Ability to analyze claims data and make informed decisions based on findings.
• Experience: Previous experience in claims processing or a related field, including supervisory experience. Understands health insurance benefit administration in a Self-Funded environmentAbility to read and understand various forms, documentation, files, and information with the department. Education and Experience: Candidate must have at least 3 years of experience with self-funded health care plans, and processing in a TPA environment Candidate must have at least 3 years of experience supervising a claims team Candidates must have prior experience with a highly automated and integrated claim adjudication system Experience working with HealthRules Payer Understanding of health insurance benefits administration in a self-funded environment
• Preferred Qualifications: Past Training Experience Experience working at TPA Experience with self-funded plans Work Location: An ideal candidate would be assigned to the Buffalo Office with ability to work from home. If not in the Buffalo area, the opportunity can be remote. Leadership Skills & Behaviors: Strategic Thinking – Knack for sorting through clutter to find the best route, often by pulling up from the current complexity to identify patterns that guide future direction and allow one to narrow the options and articulate the options from which others can work backward. Business Acumen – A keenness and quickness in understanding and dealing with a business situation (risks and opportunities) in a manner that is likely to lead to a good outcome. Critical to this is an ability to think beyond their own function. Systems/Analytical Thinking – Demonstrates the ability to think fluidly and integrate information. Able to anticipate non-linear and non-obvious relationships. Often includes an ability to think holistically/conceptually – very powerful when accompanied by ability to communicate & clarify tactically. Flexibility/Working through Ambiguity – Tendency to be energized by new experiences/perspectives that test assumptions and thinking. Considers different points of view, sometimes with fragmented information, to arrive at practical, effective, actionable next steps. Communicate – Managers discuss the company’s vision and strategies, the department’s direction and goals, and in times of crisis, what we know and don’t know to make sure team members know what they need to know. Clarify – As managers, it’s up to us to clarify what good looks like. What do we expect? What do our clients, customers or colleagues need? If our teams are not performing as expected, managers must clarify expectations and ensure understanding. Coach – Managers provide recognition and feedback; help team members find solutions to challenges; amplify good and filter weaker aspects of organizational culture and the work as they coach employees in their day-to-day performance and their growth and career development. Connect – Managers help our teams see their collective purpose and how their work connects to the greater whole. We connect people within our company and network. Customize – As managers, we need to understand what makes each team member unique, and then customize, tailor and adapt how we support them.