Claims HMO - Lead Recalculation Examiner PC# 140-1019

CommunityCare•Tulsa, OK

About The Position

The Lead Recalculation Examiner works directly with the Claims Supervisor to help create an efficient, high-performing team. The role provides guidance, instruction, and training to claims department employees, supports their development, and helps them build the skills and knowledge needed to serve customers and the company’s mission. The Lead also assists in resolving complex claims and elevated problems, and may serve as a liaison between Claims and other departments. The position coordinates daily team workflow and updates the supervisor, communicates changes that affect inquiry responses, and helps maintain a supportive and productive working environment. It processes and reviews claims, investigates coordination of benefits and other coverage, performs related clerical work, and adapts to changes in claims processing, benefits, limits, and regulations. The Lead also assists the Claims Supervisor with additional duties as needed or directed.

Requirements

High school diploma or equivalent required.
Three years of related work experience in claims processing, data entry, or medical billing.
One year of claims processing experience within CommunityCare or another healthcare environment required.
Self-motivated and able to work with minimal direction.
Ability to read and understand claims processing manuals and medical terminology, understand CPT codes, and perform claims processing procedures.
Knowledge of contracted managed care plan terms and rates.
General understanding of unbundling methods, coordination of benefits, and other over-billing methodologies.
Ability to motivate and coach employees and deliver performance-improvement feedback when necessary.
Excellent written and verbal communication skills.
Demonstrated learning agility.
Strong relationship-building skills for motivating and inspiring a team.
Proficiency 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 a Health Care Sanctions background check.
Knowledge of Network Authorization requirements.

Responsibilities

Coordinate daily workflow among employees and provide updates to the supervisor.
Assist the supervisor in regularly communicating changes that directly affect employee inquiry responses.
Solve problems while balancing company and customer needs.
Motivate the team to achieve organizational goals and contribute to company growth.
Contribute to a pleasant working environment that inspires the team.
Identify training needs and train staff on claims and company policies.
Enter claims information in claims software; process claim payments, allowable amounts, limitations, exclusions, and denials; and review system adjudication for errors.
Review and investigate appropriate claims involving coordination of benefits, workers’ compensation, and third-party coverage.
Perform clerical duties related to processing and completing claims, including pending letters and requests to load information for providers, members, or authorizations.
Handle the most difficult or complex claims and claims situations requiring significant experience and knowledge.
Learn and adapt to changes in claims processing, benefits, limits, and regulations.
Assist the Claims Supervisor with additional duties as needed or directed.
Coach employees and provide feedback that supports performance evaluation and improvement.