Claims Management Lead

About the role:

We have a great opportunity for a Claims Management Lead. The Claims Management Lead will document, execute, and improve a scalable process for Decent’s claim adjudications. This role will manage day to day operations of the claims management team including claims intake, adjudication, trend analysis, reporting ad training.

The ideal candidate enjoys partnering with numerous organizations and stakeholders to deliver outstanding claim results and is passionate about transforming the healthcare industry from fragmented fee-for-service to coordinated, financially sustainable systems.

This role will report to VP of Operations.

What you'll do:

• Manages day to day claims adjudication processes based on provider contracts, plan benefits, reimbursement policies, and state and federal regulatory guidelines
• Develops a hiring and training program to scale the claims adjudication team with Decent’s projected growth
• Drives automated adjudication rate to 90% or above with 99% first pass accuracy
• Identifies and implements reimbursement policies and claims edits that ensure fair and accurate provider payments
• Fully understand Decent’s claim processes and become a leader within Decent for all things claim related, including processes, systems, and reporting
• Manages our internal knowledge base content used during day-to-day operations as well as onboarding and training of new claims department hires

Experience:

• 3-5 years’ experience in healthcare claims management
• Working knowledge and experience in interpretation of benefit plans, including an understanding of member benefits, provider contracts, reimbursement policies, and clinical editing rules
• Experience with eligibility verification, medical coding, coordination of benefits, and subrogation
• Superior knowledge of claims adjudication software such as Facets or similar
• Ability to communicate effectively and accurately both orally and in writing
• Ability to analyze data and identify trends using excel or similar software
• Exceptional problem solving, multi-tasking and decision-making skills
• Ability to manage multiple projects at a time

Preferred Experience:

• Certified Professional Coder (from AAPC) or Certified Coding Specialist (from AHIMA)
• Experience in a leadership role within healthcare claims