Complex Claims Lead

National Healthcare Solutions Group • El Paso, TX

2d

About The Position

The Complex Claims Lead supports efficient and accurate claims processing. The role handles a range of claims activities, including year-end processing, claims adjustments, coordination of benefits, subrogation and high-dollar claims, Medicaid claims, complex appeals, hospital audits, and case management reports. The position requires careful review, sound judgment, and attention to detail, along with familiarity with claims procedures, medical terminology, and insurance policies. No supervisory responsibilities are specified.

Requirements

• At least 1–3 years of experience in claims processing or a related field.
• Strong understanding of claims processing procedures.
• Familiarity with medical terminology and insurance policies.
• High attention to detail and a focus on accuracy and quality assurance in claims processing.
• Strong analytical and problem-solving skills, including the ability to identify root causes and develop solutions.
• Experience handling escalated issues and making sound decisions under pressure.

Nice To Haves

• Associate degree preferred; an equivalent combination of education and experience is considered.

Responsibilities

• Oversee and facilitate year-end processing to ensure timely and accurate closure of claims records.
• Process claims adjustments with proper documentation and in accordance with company policies and procedures.
• Manage coordination of benefits for claims.
• Handle subrogation and high-dollar claims, applying sound judgment and attention to detail.
• Process Medicaid claims and assist with complex appeals, following applicable Medicaid regulations and procedures.
• Conduct hospital audits to ensure compliance with contractual agreements and regulatory requirements.
• Analyze case management reports and ensure they are filed to the correct member.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree