Claims Coach

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Claims Coach

Tampa, FL

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Description
Job Summary:
The Claims Coach will assist in coordinating the day-to-day work function of the claims team. This role will provide technical support to team members; investigate, review, and resolve complex issues. The role will also perform projects and research and resolve inquires.

Duties And Responsibilities

• Review, investigate, adjust and resolve complex claims, claims appeals, inquiries, and inaccuracies in payment of claims.
• Oversee claims quality reviews for accuracy, document results and identify trends and conduct systemic root cause analysis.
• Assist in creating work flows for the department and support team members in understanding changes in work processes.
• Identify and report adjudication inaccuracies that are related to system configuration, benefit inconsistency, and fee schedules.
• Primary contact for the team, for the plan and for other departments in researching, collecting background information and documentation, to address various issues; serve as a resource and SME.
• Perform advanced projects including research and determine status of claims to assure billed dollars, claims aging, and pend values are consistent with contract provisions.
• Maintain records and reports as assigned.
• Assist in meeting departmental production and quality standards.
• Process claims as needed to support the team and inventory levels.
• Develop in role, team and organization through active participation in knowledge transfer and support of engagement and initiatives.

Requirements
Required Knowledge, Skills, and Abilities:

• High School Diploma or equivalent
• 3 years of medical claims processing including knowledge of medical terminology and working in a production environment
• 1 year of experience in a senior role where team support and specialized adjudication skills were utilized is preferred
• Ability in using a computer which includes expert keyboard and navigation skills and learning new programs.
• Communicate clearly and professionally with internal and external customers.
• Work effectively as part of a team to achieve established outcomes. Understand other's roles and empower one another to take ownership to be successful.
• Demonstrate a collaborative interaction with peers to reach a common goal as well as be a resource to team members and internal/external customers.
• Pay close attention to detail in all aspects of the job.
• Effective and efficient with time management.
• Make decisions using available resources and sound judgment.
• Maintain confidentiality and discretion.
• Identify and resolve problems in a timely manner, gather and analyzes information skillfully.
• Share knowledge with associates by effectively communicating and providing follow-up.
• Open to other's ideas and exhibits a willingness to try new things.
• Demonstrate accuracy and thoroughness; monitor work to ensure quality.
• Prioritize and plan work activities to use time efficiently.
• Adapt to changes in the work environment, manage competing demands and can deal with frequent change, delays, or unexpected events.
• Follows instructions, responds to direction, and solicits feedback to improve.
• Act in such a way to instill trust from management, other associates, as well as customers.
• Work overtime as required.

Physical and Cognitive Demands:
The demands described here are representative of those necessary for an employee to successfully perform the essential functions of this job. Reasonable accommodation can be made to enable individuals with disabilities to perform the essential functions.

• Constant: Talk, hear, speak, and use hands and fingers to operate a computer, telephone, keyboard/mouse; occasionally move about the office
• Constant: Visual ability such as close vision, distance vision, color and peripheral vision, depth perception and ability to adjust focus
• Occasional: Lift and/or move up to 30-50 pounds
• Constant: Regular, predictable attendance in the office is required
• Constant: While performing the duties of this job, the employee is regularly sitting for the full shift
• Constant: The cognitive skills needed to complete tasks include abilities such as learning, remembering, focusing, categorizing, and integrating information for decision making, problem-solving, and comprehending.

Work Environment:
The work environment described is representative of what must be met by an employee successfully perform the essential functions of this job.

• The physical environment is indoors in a controlled climate, office setting. The noise level may be low to moderate.

The duties described are representative, but not restrictive of tasks that may be assigned or of the abilities required to do the job. The description is subject to change at any time. Other related duties may be assigned. This description does not alter the at-will status of employment.
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