Claims Team Lead

1 week ago

Sunrise Manor, Nevada, United States Community Care Plan Full time
Job Title: Claims Team Lead

This role is responsible for leading a team of Claims Analysts who ensure timely and accurate claim payments. The successful candidate will have a strong background in medical claims processing and adjudication workflows, fee schedules, contract terms, coverage and reimbursement policies, and claims processing standards.

Key Responsibilities:
  • Oversight of pre-payment audit reporting and payment posting process to ensure accuracy of payments being made to providers and facilities.
  • Ensures that Virtual Examiner (VE) reports are optimized based on contracts and used to apply the appropriate edits which result in financial savings.
  • Creates claim adjustments, retro adjudications due to rate changes, and reprocessing projects identified during the internal audit process.
  • Request and post claim payment refunds and recoup overpayments as necessary.
  • Reviews all identified over/under payments to determine whether claims payment discrepancies are due to system configuration, training issues or erroneous claims processing.
  • Responsible for coordinating and ensuring accurate and timely completion for testing of benefit design, contracts, and all claims related system updates and upgrades.
  • Monitor and ensure that all Customer Relationship Management (CRM) requests and inquiries to the analyst email distribution list are completed in a timely manner.
  • Responsible for first level claim appeals processing in accordance with contractual requirements.
  • Applies accurate principles, policies, procedures and regulations, including: benefit interpretation, Coordination of Benefits (COB), deductibles, co-insurance and out of pocket maximums to the adjudication process.
  • Regularly trains, assigns, coordinates, and reviews the work of staff.
  • Assists with projects and internal or external audits as needed.
  • Processes professional claims, facility claims, ad hoc vendor payments and member reimbursement requests as needed.
  • Demonstrates knowledge and understanding of all systems, product lines benefit levels, capitation and discount agreements.
  • Create and keep current internal Standard Operating Procedures and reference tools, providing related training to team members.
  • Responsible for identifying efficiencies and recommending process improvements to increase auto-adjudication rates and reduce manual processes.
  • Maintains courteous, helpful and professional behavior on the job and displays a willingness and ability to be responsive in a warm and caring manner to all customer groups.
Requirements:
  • High School or general education degree (GED); and five to seven years related claims experience and/or training. Associate degree preferred.
  • Medical Coding Certification- CPC or equivalent preferred.
  • Must have 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.
Work Environment:

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. We are committed to fostering, cultivating, and preserving a culture of diversity, equity and inclusion.

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