Medical Coding Quality Team Lead

Job not on LinkedIn

🔥 18 hours ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $65.3k - $111k / year

⏰ Full Time

🟠 Senior

🏥 Medical Billing and Coding

👻 Ghost score 20%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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PACIFICSOURCE

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

Not-for-profit health plans

📋 Description

• 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 escalate 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 PacificSource 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

🏖️ Benefits

• Work-from-home arrangement in Florida • Equal opportunity employment • Ergonomically configured equipment • Opportunities for coaching, training, staff development, and professional growth