Medical Coding Quality Team Lead

• Supervise, coach, train, and provide leadership to the Claims Audit team
• Ensure claims processing meets production, quality, policy, procedure, and workflow standards
• Evaluate team performance using reports and metrics; identify training needs
• Oversee Fraud, Waste, and Abuse claim reviews and collaborate with Compliance on potential fraud
• Support complex medical, dental, vision, self-funded, individual, and COBRA claims
• Review and research claims; determine coverage based on contracts, provider status, and processing guidelines
• Investigate and settle claims issues; support Appeals and Grievances research and responses
• Communicate business-process and procedural changes to team members
• Collaborate with the Training Coordinator on staff education
• Oversee responses to mail and email inquiries and prepare reports or correspondence
• Participate in committees, workgroups, department meetings, strategic/internal committees, and daily visual-board huddles
• Evaluate stop-loss contracts and prepare specific, aggregate, overlapping-contract, deductible, and group-number reporting
• Maintain communication with Account Managers, agents, and carriers regarding stop-loss status and administration
• Document and elevate claims-processing or system-configuration issues to the Claims Manager
• Provide expert education and support on billing/coding, medical-records review, and claims processing
• Support the Claims Refunds team with adjustments, refund letters, collections, posting refunds, balancing, and monitoring outstanding refunds
• Assist with hiring, staff development, performance reviews, corrective actions, and terminations
• Conduct one-on-ones and evaluations
• Improve interdepartmental processes using lean methodologies, visual boards, daily huddles, and performance indicators
• Follow privacy policy and HIPAA confidentiality and security requirements
• Perform other duties as assigned

Requirements

• Minimum of 4 years of complex claims management experience, including auditing, billing, research, and recovery
• At least 1 year of supervisory experience
• Experience in self-funded claims administration preferred
• High school diploma or equivalent
• Thorough understanding of Pacific Source products, plan designs, provider relationships, and health insurance terminology, or ability to learn quickly
• Basic working knowledge of Insurance Division rules and regulations
• Advanced PC skills, including Microsoft Word and Excel
• Proficient keyboarding, 10-key, multi-line phone systems, and fax machines
• Strong research and evaluation skills for accurate claims auditing
• Advanced knowledge of medical terminology and CPT/ICD-10 coding
• Ability to read and comprehend written and spoken English
• Ability to communicate clearly and effectively
• Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive typing/sorting/filing, and lift and carry files and business materials
• Approximately 5% travel required
• Core Competencies

Demonstrates expertise in complex claims management, including auditing, billing, and recovery, while providing leadership and training to the Claims Audit team.

Proficient in medical terminology, CPT/ICD-10 coding, and compliance with HIPAA regulations.

• Highest-signal resume keywords
• Claims Management Experience
• Supervisory Experience
• Medical Terminology Knowledge
• CPT/ICD-10 Coding Proficiency
• Advanced PC Skills
• Hard Skills
• Claims Auditing
• Billing
• Research
• Recovery
• Claims Processing
• Fraud Investigation
• Performance Evaluation
• Stop-Loss Contract Evaluation
• CPT Coding
• ICD-10 Coding
• Soft Skills
• Leadership
• Communication
• Training
• Collaboration
• Problem-Solving
• Industry Keywords
• Health Insurance Terminology
• Self-Funded Claims Administration
• Insurance Division Rules
• HIPAA Compliance
• Fraud, Waste, and Abuse
• Tools & Technologies
• Microsoft Word
• Microsoft Excel
• Multi-Line Phone Systems
• Fax Machines
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