Claims Specialist Team Lead

About the position

The 3rd Party Claims Specialist Team Lead is a subject matter expert (SME) on the company’s denial research methods, internal and external databases, reporting tools and policies and procedures. The Team Lead is a SME on all types of denials and functions performed by both the Claims Specialist I and Claims Specialist II and acts as a trainer and mentor to both.

Responsibilities

• Trains new employees and ensures all applicable training materials are provided and reviewed
• Provides support to staff and acts as a mentor/coach to promote a positive environment
• Provides feedback on all levels of staff to supervisor to be used in employees one on ones, check-ups and reviews
• Identifies staff performance issues and discuss with Supervisor
• Provides the necessary re-training or one on one support with staff to assist in meeting the performance expectations
• Assists management with fair distribution of work/site assignments being sure to communicate when the workloads are off balance and make suggestions on how to reconcile
• Reviews variances and write-offs submitted by staff for accuracy of information and approval requirements before giving to Supervisor for approval
• Performs monthly quality assessments on staff to ensure accuracy. Report any identified training needs to Supervisor and Manager for further review and follow-up action plan as needed
• Prepares and maintain reports and records for processing as well as run and produce miscellaneous reports as assigned or necessary
• Identifies potential financial exposure and risk to the company with underperforming or non-compliant payers
• Stays up to date on third-party billing requirements
• Monitors and provide support to those assigned to work convert billing exception reports to ensure claims are billed to accurate financial plans timely
• Completes billing transactions for non standard order entry situations as required
• Provides education to management and team members on payer specific claim processing rules, reimbursement, and other policy guidelines as gleaned by, and confirmed through working directly with payers
• Takes initiative to find opportunities and make suggestions for process improvement within the department

Requirements

• High School graduate, GED or equivalent experience.
• 3+ years insurance billing experience.
• Specialized understanding of billing requirements in one of the following areas: Medicare Part D, Medicaid, and Commercial billing.
• Understanding of revenue cycle functions within pharmacy practice or equivalent setting.
• Strong analytical skills, excellent time management and attention to details.
• Working knowledge in MS Office Products (Excel, Word) and basic computer knowledge.
• Comfortable making phone calls and interacting with internal/external entities.
• AS400, Frameworks or QS1, Computer Systems Experience.
• Communication, problem solving, detail oriented and teamwork, customer service, and accuracy.
• Strong organization skills, self-starter, and confidence.
• Must be a positive mentor to all staff.

Nice-to-haves

• Associates degree, 4 year college or technical degree.
• Pharmacy Technician.

Benefits

• Medical, Dental, Vision insurance
• Health Savings & Flexible Spending Accounts (up to \$5,000 for childcare)
• Tuition discounts & reimbursement
• 401(k)
• Company Paid Time Off
• Shift Differential
• DailyPay
• Pet Insurance
• Employee wellness and discount programs