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Lead Specialist in Claims Management
2 months ago
HarmonyCares stands as one of the largest home-based primary care organizations in the nation. We are a collective of companies dedicated to delivering high-quality, coordinated healthcare services in the comfort of patients' homes. Our family includes 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 way we care is our legacy. Every interaction matters. We strive to go the extra mile and empower one another.
Why You Should Consider Joining Us
We offer comprehensive benefits including Health, Dental, Vision, Disability & Life Insurance, and more.
401K Retirement Plan with company matching.
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 U.S. for over 28 years, making a significant impact in healthcare today.
Key Responsibilities
The Lead Specialist in Claims Management for CNC & Specialty Programs is tasked with ensuring optimal claim payments for Centene and Wellcare payers, as well as other payers involved in Health Risk Assessment and Value-Based Care initiatives.
Primary duties include but are not limited to:
- Diligently following up on unpaid, underpaid, and denied claims using weekly aging reports and biweekly A/R report distribution to staff.
- Engaging in value-based encounter denial follow-ups and filing appeals when necessary to secure maximum reimbursement.
- Establishing and nurturing strong relationships with payers while monitoring trends in denials and payment modifications.
- Collaborating closely with the department manager to communicate claims issues to the Specialty Programs Operations Team, Centene, and Health Risk Assessment Teams.
- Leading the team in problem resolution and working alongside other departments to address reimbursement challenges.
Essential Duties & Responsibilities
- Facilitate training and onboarding for new hires.
- Assist in the creation and maintenance of Standard Operating Procedures.
- Provide cross-training for current team members or specialized training for specific projects.
- Serve as the point of contact for issue resolution within the department.
- Collaborate with other Revenue Cycle Management departments or Operational teams to resolve issues.
- Compile Productivity and Quality Measures.
- Review claims that failed on Front End Edits for various reasons and analyze root causes.
- Assess and analyze insurance claims/encounters in aged and denied AR for HarmonyCares Value-Based and Centene plans.
- Access denied claims from the worklist and query claim status with the payor, utilizing all appropriate systems and websites for effective research and resubmission or appeal as necessary.
- Identify root cause denial reasons, reduce denial trends, and communicate findings to management.
- Assist the team in prioritizing claims based on aging and outstanding dollar amounts, or as directed by management.
- Learn and understand internal/external operating systems to assist staff in navigating obstacles, including but not limited to: Centricity, EDI, Waystar, and various insurance portals.
- Regularly meet with supervisors to discuss challenges or billing obstacles and provide updates on outstanding aging reports.
- Assist management in the submission and monitoring of invoices to various plans through different processes.
- Perform other duties as assigned.
Qualifications
Required Knowledge, Skills, and Experience
- High School diploma or equivalent.
- 5+ years of experience in insurance follow-up within a healthcare insurance environment with the ability to multitask.
- Proficient computer skills, particularly in Microsoft products with a strong emphasis on Excel, Word, PowerPoint, and SharePoint.
- Strong critical thinking skills for troubleshooting staff inquiries and issues.
- Knowledge of multi-specialty physician billing procedures according to Medicare, Medicaid, Commercial, and third-party payer policies, along with a basic understanding of medical terminology, ICD, and CPT codes.
- Familiarity with the value-based care model.
- Experience in filing claim appeals with various payers to ensure maximum entitled reimbursement.
- Ability to perform mathematical computations.
- Skills in problem definition, data collection, and billing information interpretation.
- Ability to work effectively with staff, patients, the public, and external agencies.
- Excellent customer service and telephone techniques, along with a high level of 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.