Medical Claims Data Processing Review Team Lead

Booz Allen Hamilton•Usa, DC

2d•Remote

About The Position

Develops, evaluates, documents, applies and implements policies, procedures or regulations to meet organizational, industry, and governmental requirements. Applies leading-edge principles, theories, and concepts; contributes to the development of new principles and concepts. Works on unusually complex problems and provides highly innovative solutions. Operates with substantial latitude for unreviewed action or decision; mentors or supervises employees in both company and technical competencies.

Requirements

Experience leading and mentoring Medicaid and CHIP Data Processing (DP) review teams.
Experience managing large-scale review operations, including planning and overseeing workloads of up to 16,150 FFS and managed care claims across onsite and remote environments.
Knowledge of MMIS, state payment systems, vendor systems, provider enrollment systems, RBS compliance requirements, and multi-system claim verification, including PBM, dental, waiver, imaging, and financial systems.
Knowledge of complex Medicaid and CHIP payment methodologies, including DRG, per-diem, capitation, PCCM, disease management, wrap payments, waiver payments, NEMT, HIPP, stop loss, and aggregate payment structures.
Knowledge of PERM documentation standards, including screen print completeness, SMERF packet assembly, qualifier and sub-qualifier requirements, cross-referencing, and defensible audit traceability.
Ability to provide SME-level guidance on complex DP determinations involving multi-system discrepancies, rate logic issues, capitation assignment, TPL workflows, RBS verification, and system anomalies.
Ability to ensure reviewers identify, document, and categorize all DP errors, including multiple errors per claim, using tools such as SMERF, review modules, and rate references.
Ability to implement and oversee QA and QC procedures, resolve escalations across Tier levels, and deliver corrective training for reviewer knowledge gaps.
HS diploma or GED.

Nice To Haves

Bachelor's degree.

Responsibilities

Ensuring correct interpretation of federal and state requirements and consistent, PERM compliant review execution.
Managing large-scale review operations, including planning and overseeing workloads of up to 16,150 FFS and managed care claims across onsite and remote environments.
Providing SME-level guidance on complex DP determinations involving multi-system discrepancies, rate logic issues, capitation assignment, TPL workflows, RBS verification, and system anomalies.
Ensuring reviewers identify, document, and categorize all DP errors, including multiple errors per claim, using tools such as SMERF, review modules, and rate references.
Implementing and overseeing QA and QC procedures, resolving escalations across Tier levels, and delivering corrective training for reviewer knowledge gaps.