Lead Specialist in Claims Management

2 weeks ago

Rochester, Michigan, United States HarmonyCares Full time
Overview
HarmonyCares stands as one of the leading home-based primary care providers in the nation. We are a collective of organizations committed to delivering exceptional, coordinated healthcare directly to patients' homes. Our family includes HarmonyCares, HarmonyCares Medical Group, HarmonyCares Home Health, and HarmonyCares Hospice.
Our Mission – To provide personalized, quality-driven healthcare to individuals facing challenges in accessing medical services.
Our Vision – Every individual deserves access to high-quality healthcare.
Our Values – Our legacy is defined by the care we provide. Every interaction matters. We strive to exceed expectations. We empower and support one another.

Why Work with Us
We offer a comprehensive benefits package including Health, Dental, Vision, Disability & Life Insurance, along with a 401K Retirement Plan featuring company matching. Additional perks include reimbursement for Tuition, Professional Licenses, and Certifications, Paid Time Off, Holidays, and Volunteer Time, as well as a structured Paid Orientation and Training program. We are proud to be recognized as a Great Place to Work and have been a leader in home-based primary care for over 28 years, making significant contributions to the healthcare landscape.

Responsibilities
The Lead Specialist in Claims Management for CNC & Specialty Programs plays a crucial role in ensuring the optimal payment of claims for various payers, including Centene and Wellcare, as well as other entities involved in Health Risk Assessment and Value-Based Care initiatives.

Key Responsibilities Include:
- Proactively following up on unpaid, underpaid, and denied claims using weekly aging reports and biweekly A/R report distributions.
- Engaging in value-based encounter denial follow-ups and filing appeals to secure maximum reimbursement.
- Building and maintaining robust relationships with payers while monitoring denial trends and payment modifications.
- Collaborating closely with the department manager to communicate claims-related issues to the Specialty Programs Operations Team and other relevant teams.
- Leading the team in problem resolution and collaborating with various departments to address reimbursement challenges.

Essential Duties & Responsibilities
- Facilitate training and onboarding for new team members.
- Assist in the creation and maintenance of Standard Operating Procedures.
- Serve as the point of contact for issue resolution within the department.
- Collaborate with other Revenue Cycle Management departments to resolve issues.
- Compile and review productivity and quality measures.
- Analyze claims that have failed on Front End Edits and determine root causes.
- Review and analyze insurance claims/encounters in aged and denied AR for HarmonyCares Value-Based and Centene plans.
- Access denied claims and query claim statuses with payers using appropriate systems and websites.
- Identify root causes of denial reasons, reduce denial trends, and communicate findings to management.
- Assist in prioritizing claims based on aging and outstanding dollar amounts.
- Learn and navigate internal/external operating systems to aid staff in overcoming obstacles.
- Regularly meet with supervisors to discuss billing challenges and provide updates on outstanding aging reports.
- Support management in the submission and monitoring of invoices to various plans.
- Demonstrate proficiency in Microsoft products, particularly in report generation using Excel, including pivot tables and formulas.

Qualifications
Required Knowledge, Skills, and Experience:
- High School diploma or equivalent.
- A minimum of 5 years of experience in insurance follow-up within a healthcare insurance environment.
- Proficient computer skills, particularly in Microsoft products with a strong emphasis on Excel.
- Critical thinking skills for troubleshooting.
- Knowledge of multi-specialty physician billing procedures according to various payer policies and a basic understanding of medical terminology, ICD, and CPT codes.
- Experience in filing claim appeals to ensure maximum reimbursement.
- Strong customer service skills and ability to maintain confidentiality.

Preferred Knowledge, Skills, and Experience:
- Associate's degree.
- Certification in Medical Billing/Coding.
- Certified Revenue Cycle Representative (CRCR).

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