Lead Specialist in Claims Management

2 weeks ago

Rochester, Michigan, United States HarmonyCares Full time

Overview
HarmonyCares stands as one of the largest home-based primary care organizations in the nation. Our family of companies is committed to delivering high-quality, coordinated healthcare directly in the home. This encompasses HarmonyCares, HarmonyCares Medical Group, HarmonyCares Home Health, and HarmonyCares Hospice.

Our Mission – To provide personalized, quality-driven healthcare to patients facing challenges in accessing care.
Our Shared Vision – Every individual deserves access to quality healthcare.
Our Values – The manner in which we care is our legacy. Every interaction matters. Go the extra mile. Empower and support one another.

Why Work with Us
We offer a comprehensive benefits package including Health, Dental, Vision, Disability & Life Insurance, and more. Additional perks include a 401K Retirement Plan with company matching, reimbursement for Tuition, Professional Licenses, and Certifications, Paid Time Off, Holidays, and Volunteer Time, along with Paid Orientation and Training. We are proud to be Great Place to Work Certified and have been a leading home-based primary care practice in the U.S. for over 28 years, making a significant impact in healthcare.

Responsibilities
The Lead Specialist in Claims Management is tasked with ensuring optimal payment of claims for various payers, including Centene and Wellcare, as well as other entities involved in Health Risk Assessment and Value-Based Care programs.

Key Duties Include:

  • Regularly following up on unpaid, underpaid, and denied claims using weekly aging reports and biweekly A/R report distributions.
  • Conducting follow-ups on value-based encounter denials and filing appeals when necessary to secure maximum reimbursement.
  • Building and maintaining strong relationships with payers while monitoring trends in denials and payment adjustments.
  • Collaborating closely with department management to communicate claims issues to relevant operational teams.
  • Leading the team in problem resolution and working with other departments to address reimbursement challenges.

Essential Duties & Responsibilities

  • Facilitating training and onboarding for new hires.
  • Creating and maintaining Standard Operating Procedures.
  • Cross-training team members or providing specialized training for projects.
  • Serving as the point of contact for issue resolution within the department.
  • Collaborating with other Revenue Cycle Management departments to resolve issues.
  • Compiling productivity and quality measures.
  • Reviewing claims that failed on Front End Edits and analyzing root causes.
  • Assessing denied claims and querying claim status with payers, utilizing appropriate systems and websites.
  • Identifying root causes of denial reasons, reducing denial trends, and communicating findings to management.
  • Assisting the team in prioritizing claims based on aging and outstanding amounts.
  • Learning and understanding internal and external operating systems to assist staff in navigating obstacles.
  • Regularly meeting with supervisors to discuss billing challenges and provide updates on outstanding reports.
  • Assisting management in the submission and monitoring of invoices through various processes.

Qualifications
Required Knowledge, Skills, and Experience:

  • High School diploma or equivalent.
  • 5+ years of experience in insurance follow-up within a healthcare insurance environment.
  • Proficient in computer skills, particularly with Microsoft products, focusing on MS Excel, Pivot Tables, PowerPoint, and SharePoint.
  • Ability to utilize critical thinking for troubleshooting.
  • Knowledge of multi-specialty physician billing procedures according to various payer policies and basic medical terminology.
  • Experience in filing claim appeals to ensure maximum reimbursement.
  • Strong customer service skills and ability to maintain confidentiality.

Preferred Knowledge, Skills, and Experience:

  • Associate's degree.
  • Certification in Medical Billing/Coding.
  • Certified Revenue Cycle Representative (CRCR).

Compensation:
Individual compensation packages are determined based on various factors unique to each candidate, including skill set, experience, qualifications, and other job-related considerations.

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