Supv, Claims

Position is responsible for overseeing the operations and functions of their Claims Units and for monitoring daily performances as it pertains to the production of claims and provider disputes, quality, inventory control, state service level timeliness agreements, and service to ensure that company goals are met. Includes leading claims and disputes activities that support these business operations: Service, Markets, IT Reporting, Audits, Compliance, Regulatory and Finance, which requires root cause analysis, trending, and process improvement activities (reporting, pricing, reimbursement, provider payment, configuration and escalated service cases).

Department: Operations

Report To: Sr, Manager Claims

Location: Tampa, FL

Essential Functions:

  • Manages and monitors key performance metrics and implements departmental policies and procedures and provide input in their development.
  • Ensure that departmental and state mandated standards and timelines are met within each unit.
  • Provide technical support to staff, markets and configuration by answering questions and resolving technical issues.
  • Supervises non-exempt direct reports assigning workload, monitoring quality and associate coaching.
  • Communicate and report departmental activities to the manager of Claims.
  • Communicate with other departments to provide information and resolve claims related issues.
  • Demonstrates business rules understandings and how claims processing works for hold logic, benefits, pricing, reimbursement, payments and denials, and provider contracts.
  • Performs the duties and responsibilities of the Manager of Claims in his/her absence to ensure that the department runs smoothly & without disruption to the daily routine.
  • Performs root cause and trending analysis on data error Reports on global issues that affect downstream processes from operation systems and business units.
  • Ensures all business processes are compliant with state and federal guidelines
  • Handles all direct employee personnel issues and processes (where applicable), including performance management, appraisal processes, development planning, and career pathing.
  • Conducts new associate training in area policies/procedures and workflow processes
  • Acts as subject matter expert for area of responsibility
  • Serves as first line contact for the company’s problem resolution procedure for associates in his/her work group.
  • Perform other duties as assigned. 
Additional Responsibilities:
    Candidate Education:
    • Required A High School or GED
    Candidate Experience:
    • Required 4 years of experience in claims management and/or managed care
    • Required 2 years of experience in Writing provider correspondence letters while using business management applications.
    • Required 2 years of experience in Claims in-house can be applied towards 4 years of experience or a related field based on operational area, i.e., customer service, claims (manual & systematic adjudication processes), call center, or a high transactional environment, accounts receivable application, etc.
    • Preferred 2 years of experience in An operational area responsible for inventory and workload management.
    Candidate Skills:
    • Intermediate Demonstrated written communication skills
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Intermediate Ability to effectively present information and respond to questions from peers and management
    • Intermediate Other Thorough knowledge of managed healthcare to include claims processing, coding, medical terminology, service, authorizations and provider contracts
    • Intermediate Other In-Depth knowledge of Health Insurance operations about manual and systematic claims adjudication.
    • Intermediate Other In-Depth knowledge and skill to create interpret and use policies and procedures that instruct staff how to process claims and provider disputes.
    Licenses and Certifications:
    A license in one of the following is required:
      Technical Skills:
      • Required Intermediate Microsoft Outlook
      • Required Intermediate Microsoft Word
      • Required Intermediate Microsoft Excel

        About us
        Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.