Insurance Submission Team Leader

Job Summary

Adjudicates incoming claims in accordance with policies, procedures, and guidelines, as outlined by the Business Unit (BU) payer contractual agreements; within mandated timeframes; and according to rates as reflected in respective paper contracts.

Job Responsibilities 1

Accurately reviews the claims prior to submission, by coding and attaching all documents related to claims.

Efficiently maneuvers through various computer systems and online resources in retrieving information while responding to customer inquiries and processing member, provider, and internal stakeholders.

Assists in managing claims inventory to ensure that claims are adjudicated in an accurate and efficient manner.

Effectively ensures that detailed electronic records are maintained by accurately documenting all actions taken.

Learns, retains, and updates one's knowledge of a wide variety of product information and internal processes and procedures, while adhering to BU rules and regulations.

Performs thorough review of pending claims for billing errors and or questionable billing practices that might include duplicate billing and unbundling of services.

Responsible for manually correcting system generated errors prior to final claims adjudication.

Works proactively to articulate findings and potential solutions.

Pre-screens all claim types for appropriate coding and documentation (including but not limited to CPT, HCPCS, ICD-10 coding)

Job Responsibilities 2

Correctly adjudicates claims for contracted/ non-contracted providers, applies policies and procedures to confirm that claims meet criteria for payment and follows contractual guidelines.

Reviews respective coding (i.e. CPT, HCPCS, ICD-10) to ensure that claims are billed in compliance with MoPH standards and corrects coding guidelines and payer standards.

Verifies presence of all required data fields and that applicable medical records are included/reviewed (where required).

Refers claims for medical claim review as necessary/applicable.

Communicates identified trends to the Team Leader for use in development of contracted provider training programs.

Identifies opportunities for claims adjudication process improvements.

Additional Responsibilities 3

Job Knowledge & Skills

Proficient in all Microsoft Office applications as well as medical office software.

Sound knowledge of health insurance providers.

Deep knowledge of Revenue Cycle Management within Billing, Collections, and Remittance posting.

Ability to work in a fast-paced environment.

Knowledge of payer websites, processes and local insurance requirements.

Effective time management and organizational skills.

Effective interpersonal and communication skills

Job Experience

Minimum 5 years of experience in Healthcare Billing/ Insurance (required).

Minimum 1 year of experience with data analytics (required).

Minimum 2 years of experience in GCC (preferred).

Competencies

Education