Claims Specialist Team Lead

Careington International is a leading non-insurance product aggregator and licensed Third Party Administrator, curating significant savings in the categories of health, wellness, and lifestyle services. Today, we serve more than 50 million members across all Careington companies, brands, products and services.

The Claims Specialist Team Lead is an important role within the Claims departments with the ability to manage and resolve high level complaints and issues. This role ensures the entire department is working at an efficient level. The incumbent has strong leadership and time management skills with the ability to work on multiple tasks at once.

This position is currently hybrid, with in-office attendance required three days per week at our Corporate Office in Frisco, TX. Please note that this role is expected to transition to a fully onsite schedule (five days per week) sometime during Spring/Summer 2027.

The Claims Specialist Team Lead is an important role within the Claims departments with the ability to manage and resolve high level complaints and issues. This role ensures the entire department is working at an efficient level. The incumbent has strong leadership and time management skills with the ability to work on multiple tasks at once.

EXPECTED WORK AND PERFORMANCE

• Responsible for managing escalated issues, complaints, and appeals to resolution.
• Assisting the Claims Manager with questions from Claims Specialists.
• Assist with training for Claims Specialists.
• Identify trends and emerging issues, to report and recommend solutions.
• Review and analyze complex appeals.
• Report trends in claims appeals and issues to leadership for root cause analysis.
• Facilitate the interpretation of the plan policy and benefit guidelines.
• Draft all resolution letters.
• Ensure the overall timely handling based on client and regulatory timeframes.
• Provide feedback to leaders for coaching and mentoring team members based on review findings.
• Reduce defects via pro-active identification of error issues as it relates to pre-payment of claims through adjudication and trends, recommending solutions to resolve these issues.
• Supports all department initiatives in improving overall efficiency.
• Performs additional duties as required and assigned, including but not limited to special projects as needed.

QUALIFICATIONS

Required

• 1+ years of experience with healthcare, specifically in appeals, claims, and/or compliance, as well as benefit interpretation.
• 1+ years of experience with client plan documents, claims research, and/or letter writing, including the documentation and interpretation of dental insurance plans.
• Advanced computer skills and experience with MS Application s- Adobe, Excel, Word, Outlook
• Skillful with computer programs and readily learns the ropes in the use of the current office applications and Careington systems.

Preferred

• Associate degree or equivalent combination of education and experience

SKILLS

• Extremely organized with the ability to effectively manage multiple tasks.
• Initiative-taking and the ability to work independently with minimal supervision.
• Aptitude to work in a deadline driven environment.
• ability to communicate clearly, orally and in writing, with the ability to effectively interact with internal and external contacts.
• Capability to apply knowledge after training so claims are researched and resolved appropriately.
• Strong work ethic and ability to adapt to new directions as business plans evolve.

PHYSICAL REQUIREMENTS

Work is performed in an office environment and requires the ability to operate standard office equipment and keyboards. Must have the ability to walk short distances.

Required to stand, walk, and sit; talk or hear, both in person and by telephone; use hands to finger, handle or feel objects or controls; reach with hands and arms. Regularly required to stoop, kneel, bend, crouch and lift up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, depth perception, color vision and the ability to adjust focus.