New Job Team Lead Eligibility Insurance Specialist In Wisconsin

Position Description: Team Lead Eligibility Insurance Specialist

Under the direction of the Independent Dispute Resolution Entity (IDRE) Project Manager or his/her designee, the Lead Eligibility Insurance Specialist provides day-to-day supervision of Eligibility Insurance Specialist team and communicates clear instructions and direction to help them achieve program goals In addition to supervision, the Team Lead performs the duties of an Eligibility Insurance Specialist and evaluates incoming requests for independent dispute resolution of contested payment for a furnished covered item or service from an Out of Network (OON) provider or facility, for nonemergency items or services from an OON provider at an in-network facility, or for air ambulance services from an OON provider of air ambulance services. The Insurance Specialist (Eligibility) reviews the documentation received determining first, if parties have standing to make an appeal, and if so then to check to make sure that the request fits within the framework of an IDRE review. In addition to review, the Insurance Specialist (Eligibility) completes all case related documentation and sends appropriate email notification as per the established workflow. They are also responsible for timely and accurate case specific data entry into the government portal.

Responsibilities:

• Understand and represent PRI's mission, vision, and values to all internal and external customers
• Interact with government and private sector clients, partners, and PRI staff in a professional and accountable manner, and as a representative of PRI management
• Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
• Proactively manages and coordinates activities to ensure timeliness of deliverables to exceed contractual obligations
• Interact with project team members in order to successfully fulfill contract obligations with the highest quality and in a timely manner meeting PRITM ISO requirements
• Instills integrity throughout the organization via active participation in ISO requirements including but not limited to timely submission of Corrective Action Plans for all matters in which either PRI standards and/or corporate contract standards have not been met. Communicating outcomes to team members to ensure a positive, open, environment which mitigates risk and achieves a culture of Continuous Quality Improvement.
• Communicates program goals and deadlines to team members
• May plan workloads and delegation of tasks to meet daily goals
• Creates a productive work environment for the team using gamification, trust and other appropriate strategies
• Assesses team performance and provides feedback to employees
• Assists with hiring and training employees
• Assists with the daily operation of the organization specific to team responsibilities
• Provides teams with information and supports recent developments, programs and policy changes of management
• Contributes to business development efforts through exceptional communications, timely, accurate determinations, documentation and professional communications.
• Utilizes project resources for research and reference verification
• Demonstrates skill and experience in handling a large workload with varying deliverable dates
• Remains flexible with assignments to meet contract performance metrics
• Demonstrates skill and experience in the submission of timely, accurate deliverables
• Demonstrates experience and skills in excellent customer service
• Has proven skill and experience in excellent oral and written communication spanning executives to the general public
• Interacts with government and private sector clients, partners, and PRI staff in a professional and accountable manner, and as a representative of PRI Performs the duties of Insurance Specialist (Eligibility) to ensure contract metrics are met
• Performs review of IDR cases as needed
• Performs other duties as requested