Claims HMO - Lead Recalculation Examiner PC# 140-1019

Job Summary

The Lead Recalculation 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. Responsible for assisting in the resolution of the most complex claims situations and to resolve elevated problems of a complex nature. May service as a liaison between Claims and other departments. 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.

Key Responsibilites

• 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.
• Handles the most difficult or complex claims or claims situations requiring significant 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.
  
  

Qualifications

• 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.
  
  

Education/Experience

• 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.
  
  

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin