Medical Coding Quality Team Lead

This is a fully remote position, open to applicants in Florida.

📋 Description

• Lead and manage the Claims Audit team, providing supervision and guidance.

• Ensure that claims processing aligns with departmental and company standards for both production and quality.

• Assess team member performance through metrics and reports; identify training opportunities and support departmental objectives.

• Oversee the review process for Fraud, Waste, and Abuse claims and assist with intricate claims documentation.

• Facilitate accurate claims services across various lines, including medical, dental, vision, self-funded, individual, and COBRA.

• Analyze and investigate medical and dental claims to determine coverage based on contractual agreements, provider status, and processing guidelines.

• Examine and resolve claims issues; communicate findings and responses for Appeals and Grievances.

• Inform team members about changes in business processes and procedures.

• Collaborate with the Training Coordinator to enhance staff education.

• Manage responses to inquiries via mail and email, and prepare necessary reports or correspondence.

• Take part in committees, workgroups, department meetings, and strategic/internal committees.

• Assess stop-loss contracts and produce manual-specific, aggregate, and overlapping-contract reports.

• Liaise with Account Managers, agents, and carriers regarding stop-loss administration and status.

• Document and escalate issues related to claims processing or system configurations to the Claims Manager.

• Provide specialized education and support on billing/coding, review of medical records, and claims processing.

• Supervise the Claims Refunds team and oversee the refund collection processes.

• Assist in hiring, staff development, performance evaluations, corrective actions, and terminations.

• Conduct regular one-on-one meetings and performance evaluations.

• Enhance interdepartmental processes using lean methodologies, visual boards, daily huddles, and key performance indicators.

• Adhere to PacificSource privacy policies and comply with HIPAA confidentiality and security regulations.

• Meet performance and attendance expectations of the department and company; perform additional duties as assigned.

⛳️ Requirements

• A minimum of 4 years of experience in complex claims management, which includes auditing, billing, research, and recovery, with proven leadership skills.

• At least 1 year of supervisory experience is mandatory.

• Preferred experience in self-funded claims administration.

• High school diploma or equivalent is required.

• Comprehensive understanding of PacificSource products, plan designs, provider relationships, and health insurance terminology, or the ability to learn.

• Fundamental working knowledge of state-specific Insurance Division rules and regulations.

• Proficient in advanced PC skills, including Microsoft Word and Excel.

• Capability to type using a standard keyboard, operate a 10-key pad accurately, and manage a multi-line telephone system and fax machine.

• Strong research skills and the ability to evaluate claims for accurate auditing.

• Advanced knowledge of medical terminology and CPT/ICD-10 coding.

• Responsible for the quality and accuracy of documents, files, and records essential for substantiating stop-loss cases.

• Ability to read and understand both written and spoken English.

• Effective communication skills.

• Physical ability to stoop, bend, sit or stand for extended periods, perform repetitive typing, sorting, and filing motions, and lift/carry files and business materials.

• Approximately 5% travel required.

🏝️ Benefits

• Competitive salary and performance-based bonuses.

• Comprehensive health, dental, and vision insurance plans.

• Generous paid time off and holiday policies.

• Retirement savings plan with company match.

• Opportunities for professional development and career advancement.