It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.
The TPL Specialist is responsible for optimizing TPL recovery efforts by identifying and investigating WellSense Health Plan members who are eligible for coverage with worker’s compensation, automobile, or general liability carriers. The TPL Specialist is responsible for partnering with our providers and members to respond to and resolve incoming COB inquiries and appeals. The TPL Specialist is expected to take complete responsibility for every interaction with a provider and a member by providing outstanding service. The TPL Specialist is responsible for establishing and negotiating liens, accurate and timely processing of TPL claims, completing activity reports, communicating TPL policies to internal and external sources, and supporting the recovery efforts of the department.
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Our Investment in You:- Full-time remote work
- Competitive salaries
- Excellent benefits
Key Functions/Responsibilities:
- Responds to provider and member phone calls and correspondence including but not limited to claim adjustment requests, appeals, corrected claims, timely filings and projects
- Investigates member accidents and identifies the liable third party carrier through phone calls, review of vendor databases, provider inquiries and claims in order to optimize savings to the Plan
- Creates and updates liens as appropriate
- Negotiates liens with attorneys effectively in order to maximize return to the Plan
- Adheres to all applicable statutory lien requirements
- Accurately processes TPL claims in Facets, including retractions, denials, repayments and secondary balances
- Handles phone calls from Customer Care Center representatives and member attorneys
- Processes all departmental reports in an accurate and timely manner and reports findings to the team lead and manager
- Participates in departmental meetings and assists in the development of workflow and process improvements
- Assists in internal departmental training programs on TPL and participates in the training of new TPL team members
- Identifies additional methods for increased recoveries through interactions with internal and external customers
- Provides technical supervision to less experienced staff as needed
Qualifications:
Education:
- Bachelor’s Degree in Business, Healthcare Administration or related fields; or an equivalent combination of education, training, and experience is required
Preferred/Desirable:
- Experience in varied methods of subrogation, TPL claims processing, and experience in a Medicaid MCO setting highly preferred
Experience:
- Four or more years of progressively responsible experience in a healthcare or managed care field required
Competencies, Skills, and Attributes:
- Knowledge of MA Comparative Negligence, PIP and Bodily Injury laws
- Strong investigative, analytical and negotiation skills
- Proficient PC skills including all Microsoft Office products required
- Candidate must be able to multi-task and prioritize work
- Must have excellent verbal and written communication skills, organizational skills and customer service skills
- Must demonstrate initiative for process improvement and have the ability to provide direction and feedback to co-workers
- Ability to work both as a team member and independently
About WellSense
WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.
- WellSense will require proof of COVID-19 vaccination(s) as a term of employment for all employees. The company may make exceptions to this requirement in certain limited circumstances for religious or medical purposes.
Required Skills
Required Experience
