Team Lead, Claims Oversight (TriZetto Facets)

Job Summary:

The Team Lead, Claims Oversight is responsible for managing and maintaining policy and performance of claim adjudication and implementation activities to ensure performance objectives are met.

Essential Functions:

• Responsible for day-to-day activities surrounding the knowledge and insight around development and support of process enhancements and process automation opportunities
• Engage in new product implementations including SME support and representation on behalf of Claims driving accurate, efficient claim processes from ideation through implementation.
• Manage and maintain workflow/assignments to ensure timely processing of claims
• Ensure prompt pay requirements are met and maintained on a daily basis
• Monitor and analyze performance trending including processing efficiency and optimal processor specialization/concentrations
• Document process changes and new procedures to promote consistency in claims operations
• Monitor level of intakes, email, mail and special projects; notify management of levels outside of established thresholds
• Create, review, revise and enforce company and department policies and procedures
• Responsible for direct supervision of staff including quality review, performance feedback, disciplinary issues and merit/bonus appraisal review
• Oversee orientation and training needs of new claims representatives
• Observe staff’s ability to utilize computer system and reference materials and make recommendations for improving performance as appropriate
• Participate in managing external vendor relationships
• Perform any other job duties as requested

Education and Experience:

• Bachelor Degree or equivalent years of relevant work/education experience required
• Minimum three (3) years claims processing experience in an HMO or related industry is required
• Minimum two (2) years data analysis experience required
• Previous supervisory/leadership experience required
• Leadership experience of claims processing via TriZetto Facets highly preferred

Competencies, Knowledge and Skills:

• Intermediate level skills in Microsoft Word, Excel and Outlook
• Facets or equivalent claims adjudication system knowledge required
• Effective written and verbal communication skills
• Leadership experience and skills
• Proven ability to lead work efforts with or without staff reporting responsibility
• Ability to work independently and within a team environment
• Strong attention to detail
• Ability to effectively support diverse personalities and work styles
• Excellent critical thinking and listening skills
• Training/teaching skills
• Strategic management skills
• Proper grammar usage
• Time management skills
• Customer service orientation
• Decision making/problem solving skills
• Knowledge of claims related applications and software
• Demonstrated ability to identify and recommend process improvements

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business