Claims Team Lead

Join us for an exciting career with the leading provider of supplemental benefits!

Our Promise
Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards.

The Claims Lead supports the Supervisor and Claims Manager in daily operations, overseeing a team of claims processors and providing technical assistance for refund and recoupment issues. Responsibilities include coordinating workflow, leading error reduction efforts, and supporting team members with claim payment procedures and accounts receivable. The Claims Lead also offers guidance on refund and recoupment adjudication, applies policies for complex benefit issues, and provides feedback on process improvements and areas of concern.

The Claims Department vision is to become the leading supplemental benefits provider, offering insurance solutions that truly work for our members. We are committed to long-term growth, both as a business and as individuals, recognizing that our people are our greatest asset and offering career development opportunities for talented professionals. Our culture is collaborative, inclusive, and rooted in integrity, with a focus on providing personalized, precision health services that promote well-being at all levels. We strive to build a best-in-class workplace where employees can thrive, ensuring a secure, healthy, and flexible environment for everyone to succeed.

The Claims Lead will monitor and assist a designated group of claims processors and provides first line technical contact for any claims refund and recoupment related issues associated with claims. Responsible for coordinating workflow, leading efforts in error reduction, and support of team members with claim payment procedures, and accounts receivable for member and providers. Provide general instruction related to refund and recoupment claim adjudication. Applies the policies and procedures as required for complex benefit issues. Provides feedback to the Supervisor, regarding refund and recoupments claims issues, process improvement opportunities and any areas of concern. Demonstrates leadership ability by encouraging positive behavior and improving efficiency.

Competencies:

• Leadership Skills: Ability to motivate, inspire, and guide a team towards achieving objectives while fostering a positive, collaborative environment.

• Communication: Strong verbal and written communication skills to clearly convey information, provide feedback, and listen to team members' concerns.

• Problem-Solving: Ability to identify issues, think critically, and implement effective solutions quickly and efficiently.

• Decision-Making: Demonstrates sound judgment when making decisions, balancing team needs and organizational goals.

• Conflict Resolution: Skilled in addressing conflicts within the team, mediating disputes, and ensuring a harmonious work environment.

• Time Management: Effective in managing both personal and team workload, prioritizing tasks, and meeting deadlines.

• Adaptability: Ability to adjust to changing circumstances, manage unexpected challenges, and remain flexible in a fast-paced work environment.

• Coaching and Mentoring: Ability to provide guidance, share knowledge, and develop team members' skills for future growth.

• Customer Focus: Prioritizing the needs and satisfaction of clients or internal stakeholders while ensuring quality and service excellence.

• Delegation: The ability to delegate tasks appropriately, ensuring that work is efficiently distributed and team members are empowered.

Functional:

• Demonstrate knowledge and understand Avesis’ contracts and performance requirements, claims processing workflow, and payment process.

• Assist Supervisor in resolving aged claims or handling of claims adjustment projects.

• Provide technical assistance to claims department staff.

• Process and evaluate difficult or non-routine claims to ensure accurate handling.

• Enter claim data accurately and timely and adjudicate claims submitted via electronic submission.

• Thorough knowledge of diagnostic and procedural coding for claims.

• Skilled use of Avesis systems and applications for claims adjudication and research of provider, member, and utilization management data.

• Timely and accurate processing of dental claims as required in contractual and regulated time frames.

• Testing of system modifications to ensure accurate processing and outcome.

• Apply policies and procedures to confirm that claims meet the criteria for payment as indicated in

• contractual guidelines.

• Presenting topics and attendance in team meetings related to claims processing reviews and updates for

• company policies and procedures, audit findings, and other related communications.

• Monitor claims inventory and make recommendations for improving outcomes.

• Ability to meet or exceed quality, accuracy, and production standards as determined by Avesis.

Core:

• Strong skills using Microsoft applications and other windows-based tools

• Exhibit strong skills for reading, writing, and communicating at a professional level

• Proficiency in managing multiple tasks and prioritizing work

• Ability to supervise and lead others, think analytically, and make independent decisions

• Ability to handle multiple and changing priorities

• Capable of maintaining positive working relationships

• Effective time management and organizational skills

• Ability to work overtime as needed

Behavioral:

• Collegiality: building strong relationships on company-wide, approachable, and helpful, ability to mentor and support team growth. 

• Initiative: readiness to lead or take action to achieve goals.

• Communicative: ability to relay issues, concepts, and ideas to others easily orally and in writing.

• Member-focused: going above and beyond to make our members feel seen, valued, and appreciated.

• Detail-oriented and thorough: managing and completing details of assignments without too much oversight.

• Flexible and responsive:  managing new demands, changes, and situations.

• Critical Thinking: effectively troubleshoot complex issues, problem solve and multi-task.

• Integrity & responsibility:  acting with a clear sense of ownership for actions, decisions and to keep information confidential when required.

• Collaborative: ability to represent your own interests while being fair to those representing other or competing ideas in search of a workable solution for all parties.

Minimum Qualifications:

• Minimum 2 years prior claims processing experience required

• As this role is a remote role, you are required to maintain internet service that allows you to complete your essential job duties without issue. Rates of 50 Mbps download and 25 Mbps upload while hardwired and not on a VPN are sufficient.

Preferred Qualifications:

• Associates degree in a related field is preferred; High School Diploma or GED is required

• Knowledge of Medicare, Medicaid, and Commercial insurance

• HCPCS, CPT, ICD 10 coding knowledge / certificate.

FLSA Status: Hourly/Non-Exempt

Salary Range: $16.68 - $26.06 per hour.

How To Stay Safe:

Avesis is aware of fraudulent activity by individuals falsely representing themselves as Avesis recruiters. In some instances, these individuals may even contact applicants with a job offer letter, ask applicants to make purchases (i.e., a laptop or gift cards) from a designated vendor, have applicants fill out W-2 forms, or ask that applicants ship or send packages of goods to the company.

Avesis would never make such requests to applicants at any time throughout our job application process. We also would never ask applicants for personal information, such as passport numbers, bank account numbers, or social security numbers, during our process. Our recruitment process takes place by phone and via trusted business communication platform (i.e., Zoom, Webex, Microsoft Teams, etc.). Any emails from Avesis recruiters will come from a verified email address ending in @Avesis.com.

We urge all applicants to exercise caution. If something feels off about your interactions, we encourage you to suspend or cease communications. If you are unsure of the legitimacy of a communication you have received, please reach out to ITsupport@Avesis.com.

To learn more about protecting yourself from fraudulent activity, please refer to this article link (https://consumer.ftc.gov/articles/how-avoid-scam). If you believe you were a victim of fraudulent activity, please contact your local authorities or file a complaint (Link: https://reportfraud.ftc.gov/#/) with the Federal Trade Commission. Avesis is not responsible for any claims, losses, damages, or expenses resulting from unaffiliated individuals of the company or their fraudulent activity.

We Offer

• Meaningful and challenging work opportunities to accelerate innovation in a secure and compliant way.
• Competitive compensation package.
• Excellent medical, dental, supplemental health, life and vision coverage for you and your dependents with no wait period.
• Life and disability insurance.
• A great 401(k) with company match.
• Tuition assistance, paid parental leave and backup family care.
• Dynamic, modern work environments that promote collaboration and creativity to develop and empower talent.
• Flexible time off, dress code, and work location policies to balance your work and life in the ways that suit you best.
• Employee Resource Groups that advocate for inclusion and diversity in all that we do.
• Social responsibility in all aspects of our work. We volunteer within our local communities, create educational alliances with colleges, drive a variety of initiatives in sustainability.

Equal Employment Opportunity

At Avēsis, We See You.  We celebrate differences and are building a culture of inclusivity and diversity. We are proud to be an Equal Employment Opportunity employer that considers all qualified applicants and does not discriminate against any person based on ancestry, age, citizenship, color, creed, disability, familial status, gender, gender expression, gender identity, marital status, military or veteran status, national origin, race, religion, sexual orientation, or any other characteristic.  At Avēsis, we believe that, to operate at the peak of excellence, our workforce needs to represent a rich mixture of diverse people, all focused on providing a world-class experience for our clients.  We focus on recruiting, training and retaining those individuals that share similar goals.  Come Dare to be Different at Avēsis, where We See You!

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