Lead Specialist in Claims Management

2 weeks ago

Rochester, Michigan, United States HarmonyCares Full time
Position Overview

HarmonyCares stands as one of the largest home-based primary care providers in the nation. Our organization comprises a family of companies committed to delivering high-quality, coordinated healthcare directly in the home. This includes 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 Vision is that every patient deserves access to quality healthcare.

Our Core 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.

Benefits of Working with Us

  • Comprehensive Health, Dental, Vision, Disability & Life Insurance
  • 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 Programs
  • Recognized as a Great Place to Work
  • Operational in 11 states
  • Over 28 years of impactful service in home-based primary care
Key Responsibilities

The Lead Specialist in Claims Management is tasked with ensuring optimal claim payments for various payers, including Centene and Wellcare, within Health Risk Assessment and Value-Based Care programs. Key responsibilities include:

  • Regular follow-up on unpaid, underpaid, and denied claims using aging reports and distribution of A/R reports.
  • Filing appeals to secure maximum reimbursement and maintaining strong relationships with payers.
  • Monitoring denial trends and communicating issues to relevant teams.
  • Leading the team in problem resolution and collaborating with other departments on reimbursement challenges.

Essential Duties

  • Facilitate training and onboarding for new team members.
  • Assist in the development and maintenance of Standard Operating Procedures.
  • Cross-train team members and provide specialized training for projects.
  • Serve as the primary contact for issue resolution within the department.
  • Collaborate with other Revenue Cycle Management departments to resolve issues.
  • Compile productivity and quality metrics.
  • Analyze claims that have failed front-end edits to identify root causes.
  • Review and assess insurance claims/encounters for HarmonyCares Value-Based and Centene plans.
  • Research denied claims and query status with payers, utilizing appropriate systems.
  • Identify root causes of denial reasons and communicate trends to management.
  • Assist in prioritizing claims based on aging and outstanding amounts.
  • Understand internal and external operating systems to assist staff effectively.
  • Regularly meet with supervisors to discuss billing challenges and provide updates on aging reports.
  • Support management in submitting and monitoring invoices to various plans.
  • Possess strong proficiency in Microsoft products, particularly Excel, including pivot tables and formula creation.
Qualifications

Required Skills and Experience

  • High School diploma or equivalent.
  • Minimum of 5 years of experience in insurance follow-up within a healthcare setting.
  • Proficient in computer applications, especially Microsoft Excel, PowerPoint, and SharePoint.
  • Strong critical thinking skills for troubleshooting.
  • Knowledge of multi-specialty physician billing procedures and medical terminology.
  • Familiarity with value-based care models.
  • Experience in filing claim appeals for maximum reimbursement.
  • Ability to perform mathematical calculations.
  • Strong problem-solving skills and the ability to interpret billing information.
  • Excellent customer service skills and confidentiality awareness.

Preferred 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 not affiliated with Harmony Hospice Care and do not conduct business in certain states.

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