Apply on Employer Site

HCA Healthcare · 1 day ago

Claims Operations Lead

United States

Full-time

Remote

Mid Level

3+ years exp

HCA Healthcare is committed to caring for patients with purpose and integrity. The Claims Operations Lead position primarily supports the unit in work distribution and accurate adjudication of claims while training and providing direction to Claims Examiners and Audit Research personnel.

BiotechnologyHealth CareHospitalMedicalPrimary and Urgent Care

Responsibilities

Adjudicates and distributes work assignments including complex claims, resolving all system edits and audits for hard copy and electronic claims in accordance with policy

Works directly with Health Plans and external vendors to resolve claims issues

Coordinates necessary workflows for verification of referral and payment on non-participating provider claims

Resolves provider and eligibility issues relating to received claims

Processes high dollar claims in accordance with procedures

Identifies potential system programming issues and assists with resolution

Performs any necessary system testing for implementation of new processes within the -400

Provides technical support and training for claims processors and claims examiners

Provides staff with any and all internal communications regarding workflows/changes

Recognizes and appropriately routes claims for carved out services according to health plan contracts

Understands health plan contracts, provider pricing, member eligibility, referral authorization procedures, benefit plans and capitation arrangements and processes claims using this knowledge

Understands general ledger accounts and posting of claims information to the appropriate accounts

Generates daily reports, assigns work, maintains weekly on hand reports

Monitors performance and claims processing times to ensure compliance with performance standards

Perform other duties as assigned

Qualification

Claims processingICD-9ICD-10CPTHCPCSClaims processing softwareMedical terminologySupervisory skillsTroubleshooting claimsDMHCCMS knowledgeHigh volume environmentTraining skillsDetail oriented

Required

Ability to communicate well with supervisors and co-workers

Knowledge of medical terminology

Knowledge of Department of Managed Health Care (DMHC), and Centers for Medicare and Medicaid Services (CMS) requirements

Knowledge of ICD-9, ICD-10, CPT, HCPCS, and revenue coding

Ability to analyze claim issues and 'trouble shoot' claims problems

Ability to act as a resource and/or trainer for claims processors and claims examiners

Technical competence with claims processing software

Supervisory skills in claims processing

Ability to work in a high volume, production-oriented environment

Detail oriented with an ability to sit for extended periods of time

Ability to work under demanding performance standards for production and quality

Ability to understand, implement and train complex claim procedures

High school diploma or equivalent

Three years of experience processing claims, with at least two years of claims examiner experience

Preferred

This role prefers candidates local to California and/or Pacific Time Zone

Benefits

Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.

Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.

Free counseling services and resources for emotional, physical and financial wellbeing

401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)

Employee Stock Purchase Plan with 10% off HCA Healthcare stock

Family support through fertility and family building benefits with Progyny and adoption assistance.

Referral services for child, elder and pet care, home and auto repair, event planning and more

Consumer discounts through Abenity and Consumer Discounts

Retirement readiness, rollover assistance services and preferred banking partnerships

Education assistance (tuition, student loan, certification support, dependent scholarships)

Colleague recognition program

Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)

Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.

Company

HCA Healthcare

Glassdoor3.3

HCA Healthcare provides medical education and healthcare services in locally managed facilities. It is a sub-organization of North Florida Endoscopy Center.

Founded in 1968

Nashville, Tennessee, USA

10001+ employees