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:

$70,800.00 - $113,200.00

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):

Salary

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.