Claims Department Lead

REPORTS TO

Assistant Manager, Claims & Appeals

JOB SUMMARY

The primary function of this job is to advise and to provide technical support to the Department Manager and other staff concerning medical claims procedures and research, especially in regard to departmental procedures for determining which services are covered medical expenses and related guidelines, reviews and appeals.

CONTACTS AND RELATIONSHIPS

This position interacts with the Health Plan staff, Plan participants, business managers, health care providers, medical insurance companies and related governmental agencies, and medical consultants. In addition to daily interaction with the Department Manager and Assistant Manager, this position also interacts with executive management whenever necessary.

ESSENTIAL FUNCTIONS

Work independently using discretion and independent judgment under the general supervision of the department managers and within broad parameters of policy established by management:

• Advise management on medical claims issues and in developing department policy guidelines for use by the examiners and PSD.
• Recommend changes to management on Health Plan language for medical benefits.
• Identify issues and related questions for claims or appeals that require physician review by Blue Cross or by other medical consultants.
• Provide guidance and expertise to claims examiners on claims questions and problem claims.
• Assist claims examiners with difficult Anthem Blue Cross professional pricing and with AWP pricing for non-network infused/injected drugs.
• Assist PSD with calls regarding medical claims issues and complex medical benefit inquiries, facilitating voluntary pre-reviews when requested and determining if case management may be appropriate for home health care.
• Perform other duties as assigned.

SKILLS AND ABILITIES

• Must have considerable knowledge of group health plan philosophy and Department of Labor health-claim regulations.
• Extensive knowledge of medical benefits, medical terminology and coding, and coordination of benefits rules.

EDUCATION AND EXPERIENCE

Seven or more years of group health claims processing at an advanced level, including extensive work in medical reviews and appeals and in writing/interpreting medical benefits language.

PHYSICAL REQUIREMENTS

Possess manual dexterity sufficient to operate standard office machines. Ability to sit or stand for extended periods of time. Position requires bending, reaching, walking, and lifting of up to 10 lbs.

Pay: $70,000.00 - $80,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Flexible spending account
• Health insurance
• Paid time off
• Vision insurance

Education:

• High school or equivalent (Preferred)

Work Location: In person