Supervise and provide leadership to the Claims Audit team, ensuring adherence to company policies, procedures, and workflows across lines of business. Manage claims production and quality to meet or exceed company standards. Resolve adjudication issues, including additional payments and recoveries. Collaborate with Grievance and Appeals to research and determine appropriate claims outcomes. Responsible for hiring, training, coaching, and evaluating team performance. Demonstrate effective leadership by fostering individual growth, team collaboration, innovation, and commitment to organizational goals.

Essential Responsibilities:

• Provide supervision, coaching, training, and leadership to assigned staff. Ensure claims processing meets department and company standards for production and quality.
• Evaluate team member performance using reports and metrics to identify training needs and support departmental goals.
• Oversee the Fraud, Waste, and Abuse claim review process. Assist with complex claims and documentation to identify potential fraud in collaboration with the Compliance team.
• Support the team in delivering exceptional claims service across all lines (medical, dental, vision, self-funded, individual, COBRA, etc.), ensuring accurate benefit interpretation.
• Oversee and assist with review, research of medical claims, and determine coverage based on contract, provider status and claims processing guidelines. Investigate and settle claims issues as needed. Relay information for dispute resolution, including research and response for Appeals and Grievances, to appropriate departments and personnel. Claims to include Dental.
• Communicate business process and procedural changes promptly to team members.
• Collaborate with the Training Coordinator on initial and ongoing education for staff.
• Oversee and assist responses to inquiries via mail or email, ensuring quality service and preparing reports or correspondence as needed.
• Participate in interoffice committees and share relevant updates with the team.
• Engage in Claims leadership peer group to promote cross-team communication, collaboration, and process efficiency with results in consistent, quality claims processing outcomes.
• Evaluate stop-loss contracts to ensure proper administration and prevent aggregate violations.
• Maintain open communication with Account Managers, agents, and carriers regarding stoploss status. Respond to inquiries regarding stoploss accounting and administration. Create manual reporting for internal and external recipients. Create manual Specific and Aggregate stoploss reporting, accounting for changes made based on claims analysis. Produce manual reporting to account for claims applying to overlapping contracts, claims applying to an aggregating-specific deductible or contracts split between a current and prior group number or third-party administrator.
• Document and escalate claims processing or system configuration issues to the Claims Manager.
• Provide expert-level education and support to other departments on billing/coding, medical records review, and claims processing.
• Collaborate with Grievance and Appeals to determine appropriate claims outcomes based on policy, contracts, and applicable laws.
• Oversee and support the Claims Refunds team with adjusting claims for refunds, sending refund letters and follow-up, sending to PRS for collection, posting refunds, balancing daily deposit and month end report. Monitor outstanding refunds and develop processes to collect.
• Maintain collaborative partnerships with key departments to coordinate business activities.
• Assist with hiring, staff development, performance reviews, corrective actions, and terminations. Conduct regular one-on-ones and evaluations.
• 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.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Actively participate as a key team member in department meetings.
• Actively participate in department meetings and strategic/internal committees to share information and represent company values.

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.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: Minimum of 4 years of complex claims management experience, including auditing, billing, research, and recovery, with demonstrated leadership capabilities. At least 1 year of supervisory experience required. Experience in self-funded claims administration preferred.

Education, Certificates, Licenses: Requires high school diploma or equivalent.

Knowledge: Thorough understanding of PacificSource products, plan designs, provider relationships and health insurance terminology or the ability to learn. Basic working knowledge of Insurance Division rules and regulations per state. Accountable for the quality and accuracy of all documents, files and records used to substantiate stoploss cases. Advanced PC skills including, Microsoft Word and Excel. Ability to type using a standard keyboard, operate 10-key pad accurately, multi-line telephone system, and fax machine. Research skills and ability to evaluate claims in order to audit accurately. Advanced skills in medical terminology, CPT / ICD-10 coding. Thorough understanding of PacificSource products, plan designs, provider relationships, and health insurance terminology, or ability to learn quickly. Basic working knowledge of Insurance Division rules and regulations. Accountable for the accuracy of documentation supporting stop-loss cases. Advanced PC skills, including Microsoft Word and Excel. Proficient in keyboarding, 10-key, multi-line phone systems, and fax machines. Strong research and evaluation skills for accurate claims auditing. Advanced knowledge of medical terminology and CPT/ICD-10 coding.

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

Compensation Disclaimer

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

Base Range:
$65,296.83 - $111,004.62

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.