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 is to provide personalized, quality-driven healthcare to patients facing challenges in accessing care.

Our Shared Vision is that every patient deserves access to quality healthcare.

Our Values emphasize that the way we care is our legacy. Every interaction is significant. We strive to go the extra mile and empower one another.

Why Work with Us

  • Comprehensive Health, Dental, Vision, Disability & Life Insurance
  • 401K Retirement Plan with company match
  • Reimbursement for Tuition, Professional Licenses, and Certifications
  • Generous Paid Time Off, Holidays, and Volunteer Time
  • Paid Orientation and Training
  • Recognized as a Great Place to Work
  • Established presence in 11 states
  • Leading home-based primary care practice in the US for over 28 years, making a significant impact in healthcare
Key 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 participants in Health Risk Assessment and Value-Based Care programs. Key responsibilities include:

  • Regular follow-up on unpaid, underpaid, and denied claims using aging reports and team communication.
  • Filing appeals to secure maximum reimbursement when necessary.
  • Building and maintaining strong relationships with payers.
  • Monitoring trends in denials and payment modifications.
  • Collaborating closely with management to address claims issues with operational teams.
  • Leading the team in problem resolution and working with other departments on reimbursement challenges.
Essential Duties
  • Facilitating training and onboarding for new team members.
  • Creating and maintaining Standard Operating Procedures.
  • Cross-training team members and 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 metrics.
  • Reviewing claims that failed front-end edits and analyzing root causes.
  • Assessing denied claims and querying status with payers.
  • Identifying root causes of denials and communicating trends to management.
  • Assisting in prioritizing claims based on aging and outstanding amounts.
  • Learning internal and external operating systems to assist staff.
  • Meeting regularly with supervisors to discuss challenges and provide updates on aging reports.
  • Assisting management with invoice submissions to various plans.
  • Utilizing advanced MS Excel skills for reporting and analysis.
Qualifications

Required Knowledge, Skills, and Experience

  • High School diploma or equivalent.
  • 5+ years of experience in insurance follow-up within a healthcare environment.
  • Proficient in Microsoft products, particularly Excel, with a focus on Pivot Tables.
  • Strong critical thinking skills for troubleshooting.
  • Familiarity with multi-specialty physician billing procedures and medical terminology.
  • Understanding of value-based care models.
  • Experience in filing claim appeals for maximum reimbursement.
  • Ability to perform mathematical computations.
  • Skill in problem definition, data collection, and billing information interpretation.
  • Effective communication skills with staff, patients, and external agencies.
  • Strong customer service and confidentiality practices.

Preferred Knowledge, Skills, and Experience

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

Minimum Pay Rate: USD $25.68/Yr.
Maximum Pay Rate: USD $31.18/Yr.

Notice

HarmonyCares and HarmonyCares Hospice are distinct entities and do not conduct business in all states.

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