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Claims Processor Lead

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POST DATE 9/16/2016
END DATE 10/16/2016

Health Choice Phoenix, AZ

Phoenix, AZ
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Entry Level (0 - 2 years)
High School Diploma or GED


JOB SUMMARY: The Claims Lead assists the Supervisor(s) and Claims Director with daily operations. Monitors and assists a specific group of claims processors and provides first line technical contact for any claims related issues related to Health Choice claims. Responsible for coordinating work-flow, lead efforts in error reduction, and support team members with claim payment procedures. Will instruct others in processing procedures and/or provide general instruction related to claim adjudication. Reviews and applies the Plan policies and procedures as required for complex health benefit issues. Provides feedback to the supervisor(s) and trainer, through written and verbal documentation/communications, regarding claims issues, process improvements and other areas of concern. Demonstrates leadership ability by encouraging positive behavior and professionalism.

Job responsibility:
Adjudicate and determine payment of claims to meet time frames determined by Health Choice, and respective contractual requirements. Apply policies and procedures to confirm that claims meet criteria for payment and are in compliance with Health Choice, regulatory requirements, and respective contractual requirements:
*Enter claim data accurately and timely according to the production goals.
*Ensure claim payments are made within time frames written in contractual agreements.
*Verify payment is not duplicated.
*Correctly adjudicate claims for contracted/ non-contracted providers.
*Ensure appropriate payment of capitated and fee-for-service providers.
*Refer claims that have already encountered to State for adjustments when applicable.
*Review CPT, HCPCS, ICD-10 coding to ensure that claims are billed in compliance with CMS and Correct Coding guidelines.
*Verify presence of all required data fields and that applicable medical records are included (when required).
*Verify that services billed are covered services.
*Confirm that an authorization exists for services that require prior authorization.
*Identify and refer third party liability or co-ordination of benefits issues to the COB/TPLCoordinator.
*Refer claims for medical claim review when necessary.
*Refer questionable issues to Claims Supervisor.
*Determine whether claims meet the outlier threshold and apply appropriate outlier payment when applicable.
*Adjudicate claims submitted via electronic submissions.
*Identify and refer potential fraud and abuse cases to the Grievance Department
Provide assistance in the day-to-day operations of Claims Department and other job related duties as assigned.
*Demonstrate understanding of automated claims processing
*Assist other claims processors as necessary.
*Interact with other departmental staff when needed.
*Provider technical assistance to claims department staff.
*Assist Claims Supervisor in resolving aged accounts.
*Monitor claims inventories and make processing recommendations to the Claims Supervisor.
Interface with Health Choice IS department and identify and participate in development of system modifications:
*Request modification/enhancements
*Test completed modifications
*Train staff in use of modifications
Demonstrate leadership behavior in individual performance as well as outcome of departmental goals:
*Demonstrate problem solving skills
*Demonstrate effective written and verbal communication skills
*Provide valid feedback to Claims Director on departmental issues and progress

Expected outcomes:
*Claims are processed within the allotted time frame provided by regulatory agencies
*Staff is maintained at an adequate level
*Policies and procedures are updated annually, or as needed
*Staff is maintained at an adequate level and receives appropriate training to perform job
*Staff have clearly defined and up-to-date job descriptions with specific goals and objectives
*Employee issues (performance, behavior, compliance with policies, etc) are addressed timely and appropriately in accordance with company policies
*Demonstrated leadership qualities and skill applications build cohesiveness within the department, increasing effectiveness and efficiency throughout the department.
*Prompt identification and communication of recognized trends and/or issues facilitates opportunities to develop and implement process improvements.
*Requests are appropriately evaluated as needed
*Staff is kept up-to-date regarding system updates and new processes
*IS and Claims work together toward mutual goals
*Demonstrated leadership qualities build cohesiveness within the department, and increases effectiveness and efficiency throughout the department

Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and managed care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment while still being valued for your individual strengths Health Choice is the place for you.

Equal Opportunity Employer Minorities/Women/Veterans/Disabled
Professional Competencies (knowledge, skills, and abilities):

Knowledge of medical terminology
Knowledge of ICD-9/ICD-10 (when applicable)
Knowledge of CPT Codes and HCPCS codes
Claims billing - 1500s and UB92s
Continuation Plans

Computer experience necessary
Effective time management and organizational skills
Effective interpersonal and communication skills

Ability to supervise and lead others
Ability to think analytically and make independent decisions
Ability to manage large workload
Ability to maintain a positive work environment for employees
Ability to maintain positive work relationships
Handle multiple and changing priorities at a fast pace
Work cooperatively, positively, and collaboratively in an interdisciplinary team

High School Diploma or G.E.D. preferred
Some college in business or health care preferred

At least three (3) years claims processing experience in CMS 1500, UB and electronic claims in a managed care environment
At least one (1) year processing claims on the Med/MC processing system preferred
At least one (1) year processing Medicaid claims

Job: Business Services/Medical Records
Primary Location: Arizona-Phoenix
Organization: Health Choice
Education Level: High School Diploma/GED
Employee Status: Full Time Benefit Eligible 36-40 hrs/wk
Work Schedule: Days