Tres Health ยท 1 day ago
Claims & Supplemental Benefits Team Lead
United States
Full-time
Onsite
Mid, Senior LevelTres Health transforms healthcare with innovative solutions focusing on elevated access and cost containment. The Claims & Supplemental Benefits Team Lead will manage and optimize supplemental health products, coordinate daily duties for analysts, and ensure claims are processed in accordance with regulations.
DentalHealth CareInsurance
Hiring Manager
Stephanie Loft, SHRM-CP
Responsibilities
Distribute claims to the analysts for daily processing. This includes answering any questions they have and going over key concepts utilized throughout the TPA industry and those specific to supplemental medical plans and benefits
Analyze supplemental products insurance claims submitted by providers, facilities, and claimants to ensure they meet policy criteria. Examine the details of the claim, including medical records, police reports, and other documentation
Determine the coverage provided by the insurance policy and evaluate the claim based on policy terms and conditions
Confirm the accuracy and authenticity of data between claims systems, eligibility feeds, and carrier files as well as all documentation submitted, including investigating potential fraud or discrepancies
Make decisions on whether the claims should be approved, denied, or adjusted, based on a thorough review of the evidence, accident letters received, COB obtained, etc
Review and evaluate claims processed by analysts to ensure accuracy, compliance, adjudication turnaround times, and payment integrity. Additionally, support internal & external audits by providing documentation, reconciliations, and process summaries
Be able to jump in and assist with any tasks or assignments provided by the management team
Adhere to insurance regulations and company policies to ensure all claims are processed in a legal and ethical manner
Other tasks as assigned
Qualification
Required
High School diploma is required
Previous experience in supplemental products claims processing, customer service, or a related field preferably in healthcare, insurance, or third-party administration (TPA) environment
Prior experience in a supervisor position would be a plus
Strong attention to detail to accurately assess and process claims
Ability to analyze complex information and make informed decisions
Strong written and verbal communication skills to interact with providers, members, and internal teams
Understanding of insurance terminology, policies, regulations, and EDI file formats
Ability to identify issues, think critically, and solve problems in a timely and efficient manner
Proficiency in using computer systems, claims management software, and basic office software (such as Microsoft Office)
Company
Tres Health
Tres Health provides alternative health insurance with dental, vision, and hearing plans, emphasizing zero deductibles and co-pays.
Founded in 2021
11-50 employees
Funding
Current Stage
Early StageLeadership Team
Michael Feeney
Co-Founder
Company data provided by crunchbase