The Claims Lead is responsible for assignment and oversight of daily claims inventory among claims examiners and vendor(s). The claims lead works closely with Management to identify and implement process improvements necessary to maintain and improve the accuracy and integrity of the claim process and increase operational efficiency. The claims lead provides supervision in the absence of the Manger, and is responsible for staff training, member and provider interfaces. The claims lead work independently, collaborating Business Intelligence, Member Services, Appeals and Grievance, Finance, Utilization Management, IT and other business units ensure the claims department meets and/or exceeds quality and performance standards.
3+ years managed care claims experience;
Knowledge of federal and state regulations pertaining to managed care, such as Title 28 regulations and Medicare Part C Claims Organization determination;
Knowledge of payment methodologies such as Medi-cal, RBRVS, APR DRG, MS DRG, and other Medicare reimbursement methodologies;
Strong understanding of health care code sets including CPT, HCPCs, ICD-10 and revenue codes;
Strong critical thinking skills, able to make timely, professional and ethical decisions;
Computer proficiency (MS Work, PowerPoint and Excel);
Excellent verbal, written and presentation skills.
High school diploma or equivalent required;
AA, or BA/BS degree preferred
Internal Number: SEA000084
About Seaside Health Plan
Let us introduce ourselves. We're MemorialCare, a nonprofit health system that includes four hospitals, two medical groups, imaging centers, surgical centers and much more. As one of the leading health systems in Orange County and Los Angeles County, we're confident that no matter what your needs are, we have the teams, tools and know-how to support you every step of the way.