[Hiring] Claims Examiner Team Lead @Local 4 SEIU Health & Welfare Fund

Role Description

The Claims Examiner, Team Lead will be a designated point of contact for all department team members, and work in a supportive leadership role to the Claims Supervisor and Claims Director. The Claims Examiner, Team Lead will effectively research and resolve daily operational issues to ensure the claims department can appropriately pay claims, respond to member and provider inquiries. The Claims Examiner, Team Lead will need a high proficiency of both collaboration and independent work to ensure members and providers are serviced timely and with high-quality standards. The Claims Team Lead will also be responsible for resolving issues related to claims processing, configuration, and appeals.

This position must be able to carry out the Claims Examiner, Level 3 description of responsibilities. This position will serve alongside other department Team Leads on assigned organizational initiatives, such as Strategic Plan tracking and updating Smartsheet. Communication with both internal and external stakeholders, and the ability to provide and lead others to carry out departmental processes to perform accurate examination of claims is vital for this role.

This position will use their expertise, analytical skills, and critical thinking to support the team in completing assignments, overseeing progress towards goals, coaching examiners as needed, performing duties in a timely manner and representing the organization in a positive manner, and understanding that attitude and behavior matters.

Key Duties and Responsibilities:

• Manage the claims department Smartsheet ticket inventory and follow up with staff to get aged tickets closed out.
• Work with staff to ensure the deadlines for claims initiatives for the organizational Strategic Plan are met.
• Research, resolve, and or provide recommendations to first level issues from the staff related to claims processing, member claim inquiries, and provider relations claim inquiries.
• Process and oversee all incoming member appeals and complaints, serve as liaison in corresponding and communicating with providers and members as needed during appeal processing.
• Act as Appeals Coordinator; educate and train claims examiner(s) on member appeals process, develop and update training manuals, assign appeal tasks to Level 2 or above claims examiner(s), monitor work, approve final product and report all productivity to management.
• Participate and present claims trends at Board of Trustee meetings when assigned.
• Attend and participate in various meetings, including monthly All Staff meetings, department meetings, training sessions, and other meetings as deemed appropriate to share, discuss, and solution for question or error trends, as well as potential process improvements.
• Create agendas using the Purpose, Outcome, and Process (POP) Model and ensure thorough notes are documented for each meeting.
• Ability to carry out key duties and responsibilities as defined for a Claims Examiner, Level 3.

Qualifications

• Associate degree or higher in Health Care, Business Administration, or similar field.

Requirements

• A minimum of five (5) years of medical PPO and HMO claims processing and health insurance experience.
• A minimum of 3 years with direct experience coordinating a team or committee to complete an operational assignment or new initiative.
• Meet or exceed 98% financial and 95% procedural for quality and production standards.
• Knowledge and understanding of the health care industry, including basic medical claim processing, subrogation, ICD-10 Diagnosis Codes, CPT Procedures Coding, HCPC Codes, HCFA 1500, and UB-02 claim forms.
• Strong understanding of plan documents and insurance policies.
• Data entry experience.
• Basic computer and keyboarding skills.
• Knowledge of basic operating system information.
• Experience with desktop computers, laptop computers, printers, copiers, scanners, fax, and other office equipment.
• Ability to type 35 words per minute accurately.
• Intermediate Level Microsoft Office skills (Word, Excel, and Outlook).
• Excellent written and verbal communication skills.
• Excellent interpersonal and customer services skills required.
• Ability to develop and maintain positive working relationships with both internal and external stakeholders.
• Strong analytical mindset.
• Ability to organize and prioritize tasks.
• Ability to demonstrate teamwork and work independently.
• Ability to meet deadlines.
• Exercise clear and concise judgment.
• Ability and willingness to assist in special projects and handle multiple tasks.

Preferred Skills

• Taft-Hartley experience.
• Knowledge of Microsoft Access.
• Knowledge of the Fund’s benefit administration system (HPS or basys).
• Experience working in a remote environment with laptop provided.
• Experience with virtual conference software (Teams and Zoom).
• Internal and external awareness of social movements, labor movements, and political issues that impact the work and the organization.

Benefits

• Comprehensive health benefit (medical, dental and vision coverage) for employees and eligible dependents, including no employee premium option for employee only.
• Competitive compensation.
• Generous holidays and PTO policies.
• Pension retirement plan.