Job Title: Medical Claims Lead

The MCP Lead functions as the team supervisor and subject-matter expert for a claims area. Responsible for creating reports, distributing workload and training new employees. Responds accurately and timely to inquiries from team members, including management, concerning claims processing and other technical issues. Investigates and initiates resolutions to complex claim problems. Identifies training gaps and assists employees to ensure consistent application of established guidelines. Identifies issues with procedures or processes and provides feedback to management on changes and development. Serves as liaison with other departments to address claim, system and quality issues. May perform some testing functions and attend/participate in meetings as needed.

Key Responsibilities
Responsible for the accurate and timely processing of medical claims in addition to their supervision dutiesResearches and processes claims according to business regulation, internal standards and processing guidelinesVerifies the coding of procedure and diagnosis codesResolves system edits, audits and claims errors through research and use of approved policies, procedures or reference training materialsCoordinates with internal/external departments to work edits and deferrals, updating the patient identification, other health insurance, provider identification and other files as necessaryExamines and processes complex or specialty claims according to business/contract regulations, internal standards and examining guidelinesDetermines whether to return, deny or pay claims following organizational policies and procedures. Corrects processing errors by reprocessing, adjusting, and/or recouping claimsEnsures that claims are processing according to established quality and production standardsResponds to routine correspondence and provides customer service support for on-line and phone call inquires and/or complaints

Required Qualifications
High School Diploma or equivalentAt least 2 years of experience processing medical claims and vouchersShall work to have a thorough understanding of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases, and Tenth Revision Clinical Modification (ICD-10-CM) standards (or latest version) within three months from their date of hireShall possess working knowledge of Microsoft Office SuiteShall have demonstrated success working in a team environment focused on meeting organizational goals, objectives, and strong customer service skillsShall have an in depth understanding of billing and follow up regulations as it relates to MedicareShall have an in depth understanding of electronic claims editing and submission capabilities including Medicare and NEIC on-line claims processing and query system

Candidates that do not meet the required qualifications will not be considered.