Claims HMO - Lead Cost Containment Specialist

CommunityCare•Tulsa, OK

65d

About The Position

The Lead Claims Examiner works directly with Claims Supervisor to create a team that works efficiently together to maximize the team's potential. The Lead will frequently provide guidance, instruction, and training to members of the claims department to achieve optimal performance. The Lead will take actions such as identification of outstanding overpayment of claims, collection of claim overpayments, managing third party claim liability, ensuring appropriate coordination of benefits, coordinating transplant claim processing and reporting of reinsurance claims to reinsurer. Focuses on helping the team build necessary skills and knowledge so they can better support customers and the company's mission. The successful team leader should be supportive, communicative, and attentive.

Requirements

Self-motivated and able to work with minimal direction.
Ability to read and understand claims processing manuals, medical terminology, CPT codes and perform claims processing procedures.
Knowledge in the contracted managed care plan terms and rates.
General understanding of unbundling methods, COB, and other over-billing methodologies.
Ability to motivate employees, coach employees and deliver performance improvement feedback when necessary.
Excellent communication skills both written and verbal.
Demonstrated learning agility.
Ability to motivate employees and provide feedback that assists in evaluating performance
Strong relationship building skills for motivating and inspiring team
Proficient in Microsoft applications.
Strong organizational and time management skills with attention to detail.
Knowledge of claims processing manuals and health benefit booklets.
Ability to maintain quality and production guidelines.
Successful completion of Health Care Sanctions background check.
Knowledge of Network Authorization requirements.
High school diploma or equivalent required.
Three years related work experience in claims processing, data entry or medical billing.
One year of claims processing experience within CommunityCare or another healthcare environment is required.

Responsibilities

Coordinates daily workflow among employees, providing updates to supervisor.
Assists supervisor with communicating regularly to employees any changes that have direct impact on inquiry responses.
Effectively solves problems that demonstrate balance of company and customer needs.
Provides motivation to the team to achieve organizational goals that contributes to the growth of the company.
Contributes to the creation of a pleasant working environment that serves to inspire the team.
Identifies training needs and trains staff in areas of claims and company policies.
Enters claims information using claims software to process claim payments, allowable amounts, limitations, exclusions and denial of claims and review system adjudication for errors.
Reviews and investigates appropriate claims for coordination of benefit, worker's compensation, and third-party coverage. Performs clerical duties associated with the processing and completion of claims including pending letters, requests for the loading of information for providers, members, or authorizations.
Manages the most difficult or complex claims or claims situations requiring considerable experience and knowledge.
Consistently learn and adapt to changes related to claims processing, benefits, limits, and regulations.
Assist Claims Supervisor in performing additional duties where needed or as directed.