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Claims Team Lead
2 months ago
This role is responsible for leading a team of Claims Analysts who ensure timely and accurate claim payments. The ideal candidate will have a strong background in medical claims processing and adjudication workflows, fee schedules, contract terms, coverage, and reimbursement policies.
Key Responsibilities- Oversee the pre-payment audit reporting and payment posting process to ensure accuracy of payments.
- Optimize Virtual Examiner (VE) reports based on contracts and apply edits to achieve financial savings.
- Create claim adjustments, retro adjudications, and reprocessing projects identified during internal audits.
- Process claim payment refunds and recoup overpayments as necessary.
- Review over/under payments to determine the cause of discrepancies.
- Coordinate and ensure accurate and timely completion of testing for benefit design, contracts, and claims-related system updates.
- Monitor and complete CRM requests and inquiries in a timely manner.
- Process first-level claim appeals in accordance with contractual requirements.
- Apply accurate principles, policies, procedures, and regulations to the adjudication process.
- Train, assign, coordinate, and review the work of staff.
- Assist with projects and internal or external audits as needed.
- Process professional claims, facility claims, ad hoc vendor payments, and member reimbursement requests.
- Demonstrate knowledge and understanding of all systems, product lines, benefit levels, capitation, and discount agreements.
- Create and maintain internal Standard Operating Procedures and reference tools.
- Identify efficiencies and recommend process improvements to increase auto-adjudication rates and reduce manual processes.
- High School or general education degree (GED); and five to seven years related claims experience and/or training.
- Medical Coding Certification (CPC or equivalent) preferred.
- Familiarity with ICD10-CM, HCPCS level II and III, CPT, revenue codes, and DRG coding on UB-04 and CMS 1500 claim types.
- Able to train staff through written, verbal, and demonstration methods.
Community Care Plan is an equal opportunity employer who recruits, employs, trains, compensates, and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.
