What are the responsibilities and job description for the Claims Team Leader - Third Party Recovery position at PacificSource Health Plans?
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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.
Supervise and provide guidance to Third Party Recovery Representatives regarding company policies, procedures, and workflow. Manage third party recovery functions for efficiency, timeliness, and quality. Resolve third party issues and oversee tracking and reporting of third party savings. Responsible for hiring, training, coaching, counseling, and evaluating team member performance. Demonstrate effective leadership by coaching to improve individual performance, develop teamwork and team support, manage change and encourage innovation, build collaborative relationships, encourage involvement and initiative, and develop increased vision and commitment to goals in others.
Essential Responsibilities:
- Provide supervision, coaching, training, evaluation, and leadership to assigned staff. Assure third party claims processing, production, and quality meet department and company standards.
- Evaluate performance of team members. Analyze results of performance reports for each team member to determine training needs related to personal performance and department goals.
- Oversee and assist in providing exceptional third party recovery service to members, providers, employers, agents, attorneys, and other insurance companies, including accurate interpretation of benefit and policy provision for all types of medical and dental policies issued by PacificSource or its subsidiaries.
- Oversee the handling of third party cases for Medicare Advantage members to ensure timely resolution and processing or reprocessing of claims. Develop and maintain communication channels between Springfield and Bend staff. Assist with development of processes and reporting tools.
- Investigate and settle third party issues as needed. Relay information for dispute resolution to appropriate departments and personnel.
- Coordinate research and response for claim-related grievances and appeals referred to Claims Department.
- Provide assistance to department staff or other departments in the review and analysis of complex medical claims requiring interpretation, chart note review, fee determination, or coding expertise.
- Communicate changes in business processes and procedures to ensure team members receive information in a timely manner.
- Serve on various interoffice committees as required or needed. Document and report any pertinent communications back to the team and/or department.
- Oversee and assist with answering inquiries received by phone, mail, or e-mail, providing exceptional service. Write original business letters and prepare reports using spreadsheet software.
- Work collaboratively with department Training Coordinator in all aspects of initial and continued education for assigned staff.
- Actively participate in Claims leadership peer group to ensure cross-team communication, collaboration and process efficiency result in consistent, quality claims processing outcomes.
- Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
Department Management
- Coordinate business activities by maintaining collaborative partnerships with key departments.
- Assist with hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.
- Assist with process improvement and work with other departments to improve interdepartmental processes. Utilize lean methodologies for continuous improvement. Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.
- Actively participate as a key team member in department meetings.
- Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
Supporting Responsibilities:
- Actively participate in department or inter-departmental workgroups. Share information or issues with department leaders.
- Regularly attend team meetings and daily team Visual Board huddle.
- Meet department and company performance and attendance expectations.
- Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
- Perform other duties as assigned.
SUCCESS PROFILE
Work Experience:
Minimum of three years of experience in closely related insurance field or three years’ supervisory experience required.
Education, Certificates, Licenses:
Requires high school diploma or equivalent.
Knowledge:
Ability to gain a thorough understanding of PacificSource products, plan designs, provider relationships, and health insurance terminology. Basic working knowledge of Oregon Insurance Division rules and regulations, as well as third party claims administration procedures and third party carrier provisions. Thorough understanding of claims processing system and operation. Advanced PC skills including, Microsoft Word and Excel. Research skills and ability to evaluate claims in order to audit accurately. Advanced skills in medical terminology, CPT / ICD-10 coding. Effective and responsive leader. Excellent communication skills. Ability to work under time pressures and deal with difficult situations. Team player. Collaborate with others and help accomplish objectives. Strong work ethic and ability to work effectively with a variety of personalities at varying skill levels.
Competencies:
Building Trust
Building a Successful Team
Aligning Performance for Success
Building Customer Loyalty
Building Strategic Work Relationships
Continuous Improvement
Decision Making
Facilitating Change
Leveraging Diversity
Driving for Results
Environment:
Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.
Skills:
Accountable leadership, Collaboration, Communication (written/verbal), Critical Thinking, Decision Making, Influencing, Listening (active), Organizational skills/Planning and Organization
Our Values
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:
- We are committed to doing the right thing.
- We are one team working toward a common goal.
- We are each responsible for customer service.
- We practice open communication at all levels of the company to foster individual, team and company growth.
- We actively participate in efforts to improve our many communities-internally and externally.
- We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
- We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
