Claims Compliance Lead

As a Claims Compliance Lead, you will play a critical role
in in ensuring the timely, accurate, and compliant processing of health
insurance claims. The ideal candidate will be responsible for monitoring claims
workflows, coordinating with internal departments, and maintaining compliance
with organizational and regulatory standards.

You will:

• Coordinate
  and monitor the daily workflow of claims processing.
• Distribute
  unprocessed claims from the Claims Queue to Claims Examiners.
• Review
  daily adjudicated claims reports to ensure accuracy and adherence to
  protocols.
• Monitor
  claim compliance by regularly reviewing Claim Reports.
• Analyze
  aged claims in Pend/Hold status and work with Examiners on timely
  resolution.
• Review
  and follow up on Pended UM, Provider Ops, Benefit Ops, and Eligibility
  reports.
• Communicate
  with supporting departments via email for claims nearing non-compliance
  deadlines.
• Return
  routed claims to examiners with guidance to ensure correct and timely
  adjudication.
• Re-run
  reports to verify all claims have been appropriately process

We are seeking a detail-oriented and proactive individual with:

• Associate Arts Degree or equivalent combination of education and experience.
• 6-8 years of medical claims payment experience in an HMO environment (i.e., MSO, IPA, or health plan) - Required
• Comprehensive knowledge of industry-standard claims adjudication policies, including CCI edits, COB determination, DOFR interpretation, and Medicare Guidelines - Required
• In-depth understanding of various fee schedules and pricing methodologies (e.g., capitation, Medicare fee schedules, DRG, APC, ASC, SNF-RUG) - Required
• Working knowledge of CPT, HCPCS, ICD-10, ASA, and Revenue Codes.
• 2-4 years of experience in processing Provider Dispute Resolutions, claim adjustments, appeals, and Reopen Guidelines - Preferred
• Familiarity with Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs).
• Strong command of medical terminology.
• Ability to key 6,000-8,000 keystrokes or type 40-50 WPM with high accuracy.
• Excellent analytical, mathematical, and problem-solving skills - Required
• Highly detail-oriented, organized, and able to follow instructions accurately.
• Ability to work independently while adhering to established procedures.
• Proficiency in Microsoft Word and Excel - Required
• Strong working knowledge of claims adjudication systems such as EPIC-Tapestry, Care Connect, QNXT, IDX - Required
  
• Goal-driven, with the ability to meet production and quality standards.