Medical Coding Quality Team Lead

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

📋 Description

• Lead, mentor, train, and provide guidance to the Claims Audit team.

• Ensure claims processing adheres to production, quality, policy, procedure, and workflow standards.

• Assess team performance through reports and metrics; identify areas for training and development.

• Supervise Fraud, Waste, and Abuse claim evaluations and work alongside Compliance on potential fraud cases.

• Support complex claims including medical, dental, vision, self-funded, individual, and COBRA claims.

• Review and investigate claims; ascertain coverage based on contracts, provider status, and processing guidelines.

• Address and resolve claims issues; assist with Appeals and Grievances research and responses.

• Convey business-process and procedural updates to team members.

• Collaborate with the Training Coordinator to enhance staff education.

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

• Engage in committees, workgroups, departmental meetings, strategic/internal committees, and daily visual-board huddles.

• Review stop-loss contracts and generate specific, aggregate, overlapping-contract, deductible, and group-number reporting.

• Maintain communication with Account Managers, agents, and carriers regarding stop-loss status and administrative procedures.

• Document and escalate claims-processing or system-configuration issues to the Claims Manager.

• Provide expert education and assistance 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 evaluations, corrective actions, and terminations.

• Conduct one-on-ones and performance evaluations.

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

• Adhere to privacy policy and HIPAA confidentiality and security protocols.

• Perform additional duties as assigned.

⛳️ Requirements

• A minimum of 4 years of experience in complex claims management, including auditing, billing, research, and recovery.

• At least 1 year of supervisory experience.

• Preferred experience in self-funded claims administration.

• High school diploma or equivalent required.

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

• Basic working knowledge of Insurance Division rules and regulations.

• Advanced PC skills, including proficiency in Microsoft Word and Excel.

• Skilled in keyboarding, 10-key operations, multi-line phone systems, and fax machines.

• Strong research and evaluation abilities for precise claims auditing.

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

• Proficient in reading and comprehending both written and spoken English.

• Capable of clear and effective communication.

• Ability to stoop, 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.

🏝️ Benefits

• Work-from-home arrangement in Florida.

• Commitment to equal opportunity employment.

• Ergonomically configured work equipment.

• Opportunities for coaching, training, staff development, and professional growth.