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Claims Team Manager

Please Note: The application deadline for this job has now passed.

Job Introduction

Supervises a group of Claim assessors and ensures that claims are processed effectively within established deadlines, in accordance with procedures and directives. Randomly evaluate claims and ensure that appropriate care is provided, billing is correct, and claims are processed within policy plan and company standards and objectives. Ensures complete claim settlements and reviews when necessary.

Role Responsibility

  • Oversees the work schedule, attendance, vacation authorization and work load allocation for staff. Ensure department claim processing guidelines and objectives are met.
  • Runs daily report to assess volume of claims, balances workload of the Claims assessors as needed to ensure department objectives and deadlines are met.
  • Evaluates staff’s performance, provides support, coaching, counselling, and training external and internal to enhance performance; thus maximizing efficiency and developing potential.
  • Builds positive relationships with Providers and Policy holders through outstanding service.
  • Reviews, processes and releases payment to policyholders and providers.
  • Utilizes reports to ensure level of quality is in line with department requirements. Ensures processing is in compliance with company procedures, the confines of the policy, the medical diagnosis and within the network rates or usual and customary rates.
  • Monitors information entered into system, tracks errors and addresses immediately to prevent monetary or legal impact to the company.
  • Monitors and evaluates trends, identifies potential areas that can cause errors in processing, procedures, and company practices and recommends changes.
  • Identifies ways to avoid rejection of claims payment from providers and minimizes future errors.
  • Interacts with the other managers in other departments to assure consistency across the different policies and to evaluate exceptions of company policies and/or administrative decisions.
  • Coordinates with Providers Department to resolve claims questions and concerns as needed.
  • Balances work load for assigned group and redistributes as necessary to meet department goals and exceed customer expectations.
  • Ensures that team is aware of any policy or procedure changes that will affect their area of expertise.
  • Attends management meetings, conducts team meetings and ensures team is aware of policy and other changes that may affect the area.
  • Performs other related tasks as assigned.

The Ideal Candidate

  • 4 year college degree and significant related experience.
  • 8-10 years insurance industry experience with 3-4 years in Claims processing.
  • Previous supervisory experience 2-3 years preferred year.
  • Previous customer service experience preferred.
  • Bilingual English and Spanish read and write with excellent communication skills in both languages.  Portuguese a plus.
  • Knowledge of medical terminology or experience within the health care field is recommended.
  • Basic knowledge of commonly-used concepts, practices, and procedures within the insurance industry.
  • Intermediate to advanced knowledge of MS Office software; Outlook, Word and Excel. Knowledge of PowerPoint a plus.


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