$100k Per Year

Job Type



12 days ago




Position Summary:

Team Lead Claims is responsible for management of the daily workflow and the leadership of the claims examination department staff. This position requires an experienced examiner with the authority to ensure that the unit meets all quality, production and timeliness standards in the adjudication of the company claims. This position is primarily a day-to-day production role. The Team Lead must be able to assist the management team within the Claims Department in leading change and promoting a positive team attitude and be able to effectively respond to unexpected changes or demands.

The Claims Lead performs various audits of claims denials, payments, pre and post check, targeted audits, focused audits, health plan readiness audits, and denials to ensure payment accuracy and integrity based on industry standards, the DOFR agreements and federal/state regulatory requirements.

Essential Job Functions:

•             Conducts pre- and post-payment audits to ensure accurate claims payments and denials

•             Utilizes knowledge of DOFR (Division of Financial Responsibility) and Medicare, and Commercial requirements to conduct thorough reviews of all parts of the claims process.

•             Gathers relevant audit data, prepares audit reports, and makes recommendations for process improvements based on audit findings.

•             Strong knowledge of claims processing standards to ensure regulatory compliance and to improve overall quality and efficiency.

•             Identifies and appropriately escalates any audit-related problems to immediate supervisor.

•             Supports and facilitates external audits and projects as directed.

•             Contributes to team effort by accomplishing related results based on performance metrics as needed.

•             Recommends training needs based on error patterns.

Other Job Functions:

•             Work independently and as part of a team.

•             Develop and maintain effective working relationships with all levels of staff and providers.

•             Handle multiple tasks and meet deadlines.

•             Effectively utilize computer and appropriate software and interact as needed with health Claims Processing Systems.


Required Qualifications:

Minimum Experience

•             High school graduate or equivalent. High School diploma

•             3+ years claims processing experience in a managed care environment.

•             1-3 years Claims Audit experience preferred.

•             Experience processing Medicare, Medicaid and Commercial claims preferred.

•             Must have good customer service skills.

•             Strong oral and written communication skills.

Skills and Abilities:

•             Revenue Codes, CPT-4/HCPCS, ICD-10 codes.

•             Industry pricing methodologies, such as RBRVS, Medi-Cal and Medicare Fee Schedules, MS-DRG, APR-DRG, etc.

•             Medical terminology.

•             Benefit interpretation and administration.

•             Medicare, Medicaid, and Commercial guidelines and regulations.