Zenith American Pittsburgh, PA
- Posted: over a month ago
Title: Supervisor, Claims
Position Type: Non-Exempt Hours per Week: 40
Provides daily leadership and supervision to Claims team consistent with management values and mission. Assigns, distributes and monitors quality and quantity of work produced, ensuring employees are held accountable for consistently meeting quality and production requirements. Develop staff through performance management, goal setting, training, and effective employee relations. Review and approve timecards, time off requests, and the accuracy of labor allocations and payroll processing information. Optimize workflows/processes, tools, staff allocation, and technology to ensure efficient and cost effective day to day operations. Implements and monitor internal systems, policies and procedures to ensure operations are in compliance with client needs, new developments, regulations, and reporting requirements. Takes on Lead and Specialty Duties as assigned.
"Has minimum necessary access to Protected Health Information (PHI) and Personally Identifiable Information (PII) by Job Description/Role."
- Performs technical review and analysis to determine benefit allowance and benefit category on all types of claims, including large dollar and technically complex claims.
- Investigates, evaluates and generates reports related to stop-loss, accident, medical malpractice, subrogation, and/or Worker's Compensation cases for third party recovery.
- Coordinates appeals through research and documentation, and generates denial and/or approval letters.
- Reviews processed claims, including hospital, medical, and timeloss for accuracy, HIPAA and DOL compliance, and appropriateness of benefits paid.
- Compiles audit information, provides progress reports and training, and makes recommendations to management as appropriate.
- Reviews and interprets new benefit plans and/or benefit plan changes, tests benefits, develops resource materials and acts as a resource for staff and management, including handling elevated calls.
- Manages claims system maintenance, including coordination of configuration change, uploads and data transfers with the IT department.
- Participates in developing claims processing policies, procedures and training.
- Maintains communications and effective working relationships with clients, government agencies, unions, participants, attorneys, and consultants as required.
- Identify issues and problems, develop solutions, and prepare recommendations, including policies and procedures.
- Ability to exercise independent judgment, manage multiple priorities and consistently deliver high-caliber results.
- Strong attention to detail
- Must be strong team player with the confidence and integrity to earn internal team confidence and partnership.
- Must have high degree of professionalism, maturity, integrity and commitment to customer satisfaction.
- Must have ability to effectively communicate concerns with internal and external customers in a professional and productive manner.
- Should be strong decision-maker and have strong organizational skills, with the ability to optimize the use of all available resources and deliver on multiple priorities.
- Should have strong analytical and problem resolution skills; ability to exercise independent, sound judgment.
- Proficient PC skills including intermediate to advanced Microsoft Word, Excel and Outlook skills.
- Bachelors Degree Preferred
- Minimum of five years of claims experience in a TPA environment, handling all types of claims as well as complex claims.
- Minimum of 3 years supervisory experience, preferably in an insurance, benefits, or TPA environment. Experience with claims metrics and analysis, staffing models and workforce management, and managing a remote workforce preferred.
- Ability to read and interpret documents such as procedure manuals and health plans.
- Ability to speak effectively and present information in one-on-one and small group situations to customers, clients, and other employees of the organization.
- Ability to calculate figures and amounts such as discounts, interest, proportions, and percentages.
- Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
- Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
- Ability to meet production and quality goals on a consistent basis.
- Excellent verbal and written communication and strong interpersonal skills.
- Proven attention to detail, follow-through skills and problem solving skills.
- Exceptional team player with the confidence and integrity to earn client and internal team confidence quickly.
- Accomplished change leader, demonstrating a flexible approach and resilience to setbacks. Able to drive operational and cultural change.
- Proven ability to recruit, lead and motivate a team in order to balance staffing strength with profitability and growth.
- Thorough understanding of claims operations and processes, to include payment of claims, interpretation of contracts, communication of benefits, etc.
- Excellent verbal and written communication skills, including interpersonal skills.
- Strong decision-making and organizational skills, with the ability to optimize the use of all available resources and deliver on multiple priorities.
- Exceptional analytical and problem resolution skills; ability to exercise independent, sound judgment.
- Proficient PC skills including intermediate to advanced Microsoft Word, Excel and Outlook skills. PowerPoint experience preferred.
- Communicate effectively both verbally and in writing, including public presentations.
- Collect data, identify pertinent information and prepare reports and presentations.
- Project management skills, well organized, and detailed oriented preferred.
- Development and presentation of training tools and materials required.
- Knowledge of: Claims managed care benefits and adjudication. Benefit knowledge of Medicare and Medi-Cal. Services, policies, and general responsibilities and requirements/regulations of program to which assigned.
- Practices and techniques required to function with other professionals working in the assigned program. Methods and techniques for organizing and implementing programs or projects.
Zenith American Solutions
Real People. Real Solutions. National Reach. Local Expertise.
We are currently seeking an experienced Supervisor, Claims with the necessary skills, initiative, and personality, along with the desire to get the most out of their working life, to help us be our best every day.
Zenith American Solutions is the largest independent Third Party Administrator in the United States and currently operates over 40 offices nationwide. The original entity of Zenith American has been in business since 1944. Our company was formed as the result of a merger between Zenith Administrators and American Benefit Plan Administrators in 2011. By combining resources, best practices and scale, the new organization is even stronger and better than before
We realize the importance a comprehensive benefits program to our employees and their families. As part of our total compensation package, we offer an array of benefits including health, vision, and dental coverage, a retirement savings 401(k) plan with company match, paid time off (PTO), great opportunities for growth, and much, much more!
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