Senior Claims Operations Lead

Job Summary A process leader leads, monitors, and administrates a group of employees to achieve goals that contribute to the organization's growth. Process leaders motivate and inspire their team by creating an environment that promotes positive communication, encourages bonding of team members, and demonstrates flexibility. Responsibilities Working with the Claims Manager, p rovides daily direction and communication to employees so that the business deliverables are intact, efficient, and knowledgeable manner .

• Monitoring operational activities of claim examiners to ensure claims are processed accurately and timely.
• Provide technical support, expert advice, and coaching assistance to team members and clients.
• Identify new opportunities to improve operational effectiveness and customer satisfaction and make recommendations for improvements.
• Identify skill gaps and ensure training is provided to further develop staff.
• Should be aware of KRAS, KPIS, SLA, AHT, Occupancy, Attrition, Shrinkage.
• Should be able to manage team conflict and any people related issue
• Should have experience and able to handle complaints, DOI, Appeal etc.
• Adhere to process reporting, able to draft process documents, including SOP, Update tracker, issue logsetc.
• Ability to do quality audit for team process
• Ability to speak to client on process related issues and able to handle the calls with client

Qualifications

• To perform this job successfully, the individual must be able to perform each essential duty effectively.
• The individual must possess advance product knowledge, comprehensive understanding of insurance terminology and definitions, core knowledge of company and department processes and procedures related to the ability to complete job responsibilities /duties in a proficient and professional manner.
• Must have knowledge of medical terminology, ability to read and interpret most medical records/notes, ICD-9/ 10 and CPT/HCPC/CDT coding; Familiarity with different medical claim forms, i.e. HCFA-1500 and UB04 forms; working knowledge of Insurance Industry and/or Healthcare.

Education -Exper ience One to Two years certificate/degree from college or technical school; or 2-5 years related experience and/or training; or equivalent combination of education and experience. Language Skills Must have the ability to read and interpret documents such as policies and operating and procedural manuals; Ability to write routine correspondence; Ability to speak effectively to customers, clients or employees of the organization. Competencies Critical Thinking; Customer Service; Work Standards; Decision-Making; Communication; Interpersonal Skills; Integrity/Honesty and Adaptability/Flexibility Mathematical Skills Must have the ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals; Ability to calculate figures and amounts such as discounts, interest, and percentages. Reasoning Ability Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form;Ability to deal with problems involving several concrete variables in standardized situations. #J-18808-Ljbffr Wellcove