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Lead Claims Specialist
2 months ago
The Lead Claims Specialist plays a pivotal role in overseeing the daily management of claim challenges for prominent providers. This position serves as the primary contact for assigned accounts regarding any claim-related inquiries. Acting as a liaison and advocate, the Lead Claims Specialist collaborates with internal departments and practice managers through various communication channels to address and resolve outstanding claim matters. This role also engages with Provider Contracting and Provider Relations teams to manage the operational facets of provider relationships and participates in internal meetings to present findings and research on claims-related issues. As a claims subject matter expert (SME), this position handles incoming inquiries about current claims and escalated concerns, contributing to strategic planning for assigned accounts and ensuring prompt resolution of open issues.
Key Responsibilities:
Responsibilities encompass, but are not limited to:
- Acting as the SME and leader on functional deliverables to ensure efficiency across all responsibilities.
- Monitoring and maintaining records of known issues, including operational provider issue logs, and developing work plans to enhance claims accuracy and address systemic challenges that affect efficiency or provider satisfaction.
- Conducting in-depth research on complex payment discrepancies and documenting root cause analyses and mitigation strategies.
- Timely responding to correspondence regarding escalated issues.
- Executing necessary claim adjustments for overturned determinations directly within the HealthRules system.
- Requesting appropriate adjustments via AWD to the Claims BPO.
- Representing the organization to both internal and external customers in a professional manner.
- Participating in both ad-hoc and regularly scheduled operational meetings with the provider community.
- Documenting outcomes from meetings and calls, ensuring timely resolutions.
- Collaborating with other departments to identify and resolve claim payment issues, including opening JIRA tickets as necessary.
- Providing support and guidance to all Claims teams on identified system challenges.
- Partnering with the Documentation Specialist to develop desktop procedures.
- Assisting in the testing of new functions, features, system upgrades, and new implementations.
- Undertaking additional duties or special projects as assigned.
- Upholding Corporate Compliance Responsibility by adhering to the organization’s Corporate Compliance Program, Standards of Business Conduct, and all applicable laws, rules, and regulations relevant to individual job duties and the department.
Required:
- Associate's degree or equivalent relevant work experience.
- A minimum of five (5) years of experience in a managed care or healthcare-related organization.
- At least one (1) year of experience directly interacting with the provider community.
- Strong understanding of claims adjudication, processing, and analysis.
- Ability to manage multiple projects simultaneously.
- Proven experience in building and maintaining strong business relationships with providers.
- Ability to analyze business systems and identify deficiencies and opportunities.
- Understanding of provider reimbursement mechanisms.
- Intermediate to advanced proficiency in Microsoft Office Suite.
- Basic knowledge of contract implementation and contract language.
- Excellent judgment and ability to work both independently and collaboratively.
- Exceptional listening, verbal, and written communication skills.
- Strong problem-solving skills with meticulous attention to detail.
- Comprehensive knowledge of all organizational products and services.
- Familiarity with resources available within the organization for resolving internal and external issues.
- Strong information management skills, including the ability to organize information and identify complex service delivery issues.
- Knowledge of HIPAA standards and CMS guidelines.
Preferred:
- Bachelor's degree.
- Coding Certification from AAPC or AHIMA.
- Prior experience with JIRA or similar project tracking systems.
- Experience with coding programs or websites.
- Prior experience in Network Management.
- Project Management experience.
Core Competencies:
- Effective Communication
- Respect for Diversity
- Analytical Problem Solving
- Customer Success Orientation
- Performance Management
- Adaptability to Change
Job-Specific Competencies:
- Team Collaboration
- Relationship Building
- Attention to Detail
- Sound Judgment and Decision Making
Flexible Work Arrangement: Yes
Telecommuting Arrangement: No
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
