What are the responsibilities and job description for the Quality Assurance Audit Team Lead position at PacificSource Health Plans?
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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.
The Quality Assurance Audit Team Lead provides supervision, leadership, and guidance to Claims Analysts, Quality Assurance Audit Specialists, Reinsurance Business Analysts, and support staff, ensuring adherence to company policies, procedures, and workflows. This role is responsible for managing claims production and quality to meet or exceed company standards, resolving adjudication issues, and overseeing hiring, training, coaching, and performance evaluation. As a leader, the Team Lead fosters a collaborative and inclusive team culture, encourages innovation, and supports management change. They coach team members to improve individual performance, build strong team dynamics, and inspire commitment to shared goals and organizational vision.
Essential Responsibilities:
- Supervise, coach, train, and evaluate assigned staff to ensure claims processing meets department and company standards.
- Analyze performance data to identify individual and team training needs and support ongoing development.
- Collaborate with the Training Coordinator to deliver effective onboarding and continued education for team members.
- Oversee and support accurate and timely processing of medical and dental claims, ensuring correct interpretation of benefit and policy provisions.
- Assist with claim review and research to determine coverage based on contract terms, provider status, and processing guidelines.
- Investigate and resolve claims adjudication issues, including disputes, and coordinate with appropriate departments to support grievance and appeal processes.
- Respond to inquiries received by mail or email, and prepare clear, professional business correspondence and reports.
- Communicate updates to claims-related processes and procedures to ensure team alignment and timely adoption.
- Participate in interoffice committees and leadership peer groups to promote cross-functional collaboration and process efficiency.
- Coordinate with other departments to support business activities and maintain effective partnerships.
- Ensure compliance with HIPAA regulations and PacificSource privacy policies regarding the confidentiality and security of protected health information.
- Support process improvement initiatives using lean methodologies and contribute to interdepartmental efforts to enhance workflows.
- Use visual boards and daily huddles to monitor key performance indicators and identify opportunities for improvement.
- Actively contribute to department meetings and strategic committees to share insights and represent company values.
Supporting Responsibilities:
- Meet department and company performance and attendance expectations.
- Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
- Perform other duties as assigned.
SUCCESS PROFILE
Work Experience: Minimum of 4 years of claims experience, or related experience in insurance or healthcare industry required. Minimum of 1 year of supervisory experience required.
Education, Certificates, Licenses: Requires high school diploma or equivalent.
Knowledge: Ability to gain a thorough understanding of PacificSource products, plan designs, provider relationships, and health insurance terminology. Basic working knowledge of Oregon Insurance Division rules and regulations. Thorough understanding of claims processing systems and operations. Advanced PC skills including Microsoft Word and Excel. Ability to type using a standard keyboard, operate a 10-key pad accurately, and use a multi-line telephone system and fax machine. Strong research skills and ability to evaluate claims for accurate auditing. Advanced knowledge of medical terminology and CPT / ICD-10 coding. Effective and responsive leadership skills. Ability to stay current with changes in PacificSource business processes and procedures and communicate updates to team members. Ability to work under time pressure and manage difficult situations. Collaborative team player with a strong work ethic and ability to work effectively with individuals at varying skill levels.
Competencies
Building Trust
Building a Successful Team
Aligning Performance for Success
Building Customer Loyalty
Building Strategic Work Relationships
Continuous Improvement
Decision Making
Facilitating Change
Leveraging Diversity
Driving for Results
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.
Skills:
Accountable leadership, Collaboration, Communication (written/verbal), Critical Thinking, Decision Making, Influencing, Listening (active), Organizational skills/Planning and Organization
Our Values
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:
- We are committed to doing the right thing.
- We are one team working toward a common goal.
- We are each responsible for customer service.
- We practice open communication at all levels of the company to foster individual, team and company growth.
- We actively participate in efforts to improve our many communities-internally and externally.
- We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
- We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.