Project Lead - Claims Adjucation

Job Title: Claims Operations Team Leader

Department: Operations/Claims

Reports To: Claims Operations Manager

Years of Expereince: 5 to 7 Yrs

Position Summary:

 

The Claims Operations Team Leader is responsible for overseeing and monitoring the day-to-day functions of the claims department to ensure the accurate and timely processing and release of all incoming claims. This role requires exceptional attention to detail, strong organizational and leadership skills, and a steadfast commitment to maintaining the highest standards of data integrity, compliance, and confidentiality.

Essential Duties and Responsibilities

• Supervise the operational performance of claims payment accuracy and timeliness.
• Design job aids for the department.
• Proactively identifies configuration issues through regular monitoring of examiner audits and provider complaints
• Performs root cause analysis to diagnose systemic issues and communicates findings to management for corrective action planning
• Coordinate with Provider Operations to review and resolve provider data issues
• Implements and administers a robust training program.
• Assists with inventory management and related tasks as needed.

Competency                                             

To perform the job successfully, an individual should demonstrate the following competencies:

Analytical - Synthesizes complex or diverse information; Collects and researches data.

 

Design - Demonstrates attention to detail.

 

Leadership - Exhibits confidence in self and others; Inspires and motivates others to perform well; Effectively influences actions and opinions of others; Accepts feedback from others; Gives appropriate recognition to others.

 

Technical Skills - Assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others.

 

Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.

 

Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem-solving situations.

 

Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.

 

Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Remains open to others' ideas and tries new things.

 

Oral Communication - Speaks clearly and persuasively in positive or negative situations; Listens and gets clarification; Responds well to questions; Participates in meetings.

 

Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.

 

Teamwork - Exhibits objectivity and openness to others' views; Gives and welcomes feedback.

 

Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.

 

Cost Consciousness - Works within approved budget; Contributes to profits and revenue; Conserves organizational resources.

 

Diversity - Shows respect and sensitivity for cultural differences.

 

Ethics - Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethically; Upholds organizational values.

 

Judgment - Supports and explains the reasoning for decisions; Includes appropriate people in decision-making process.

Motivation - Sets and achieves challenging goals; Demonstrates persistence and overcomes obstacles; Measures self against standard of excellence.

 

Planning/Organizing - Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Sets goals and objectives.

 

Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.

 

Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.

 

Quantity - Completes work in a timely manner; Strives to increase productivity; Works quickly.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

 

A minimum of 5 to 7 years of Medicare experience in Managed Care preferred with a focus in claims and benefit configuration, claims operations internal and external; and payment accuracy preferred.

 

Knowledge of CPT Codes, DRG, and ICD-10 billing coding for institutional and professional claims is a must.

 

Language Skills                                         

Fluent in English with strong verbal, written, and reading communication skills. Able to read and comprehend instructions, prepare concise written communications, and effectively present information in one-on-one or small group settings to members, providers, clients, and internal staff. Must also be comfortable actively participating in meetings and communicating confidently with team members.

Mathematical Skills                                                      

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage and to draw and interpret bar graphs.

Reasoning Ability                                                      

Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.

Computer Skills                                         

 

Must be highly proficient in Microsoft 365 applications, including Word, Excel, Outlook, and Teams, with the ability to efficiently leverage these tools for daily operations.

Other Qualifications                                                      

Previous experience in Managed Care and Medicare preferred.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee must occasionally lift and/or move up to 10 pounds.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.