Claims Manager

OPERATING ENGINEERS LOCAL 139 HEALTH FUND•Village of Pewaukee, WI

54d•Hybrid

About The Position

The Claims Manager is responsible for supervising, coordinating, and implementing a wide range of departmental projects and programs, as well as overseeing the day-to-day operations of the Claims Department. The Claims Department processes medical, dental, vision, disability, and HRA claims and provides customer service support to participants.

Requirements

Post–high school education and/or relevant work experience preferred.
Five or more years of experience in an automated claims processing or benefits administration environment.
At least two years of management or supervisory experience.
Thorough knowledge of claims operations, including claim payment, contract interpretation, and benefit communication.
Ability to read and interpret documents such as Summary Plan Descriptions and Plan rules.
Ability to communicate clearly and professionally with participants and internal departments.
Ability to apply common sense understanding to carry out detailed written or oral instructions.

Responsibilities

Process and audit all types of claims—including medical, dental, vision, HRA, and loss-of-time (short-term disability)—for active members and retirees.
Ensure claims are processed accurately and meet quality, timeliness, and production standards.
Research and resolve appealed, questionable, or denied claims to ensure fair and timely outcomes.
Conduct phone monitoring to ensure quality service.
Respond promptly and professionally to phone, written, and walk-in inquiries from participants, trustees, employers, and union representatives.
Draft written correspondence regarding claim inquiries, determinations, and appeals.
Coordinate programming updates and client communications for Plan changes.
Run reports as needed. Analyze report data and notify Administrative Manager of concerns or recommendations for improvement.
Collaborate with consultants, attorneys, and management on benefit interpretations, subrogation, workers’ compensation, and preparation of plan materials and booklets.
Communicate and collaborate with vendors such as PBM, PPO, UR, Case Management, etc as needed.
Support efforts to improve electronic claims productivity and auto-adjudication rates.
Perform other special projects as assigned.
Ensure employees follow organizational policies and procedures.
Manage scheduling for PTO, assign overtime, and arrange coverage for absent staff.
Regularly assess departmental and employee needs to maintain efficient operations.
Develop individualized training plans to ensure employees have the expertise required for their roles; provide ongoing coaching and guidance.
Prepare agendas for regular staff meetings.
Maintain performance standards for staff roles, provide constructive feedback, and identify opportunities for improvement.
Develop performance improvement plans when necessary, as well as recognize and reward strong performance.