Medical Coding Quality Team Lead

Job not on LinkedIn

🔥 17 hours ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $65.3k - $111k / year

⏰ Full Time

🟠 Senior

🏥 Medical Billing and Coding

👻 Ghost score 0%

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.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

PacificSource Health Plans

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

PacificSource Health Plans is a healthcare provider that offers a range of health insurance solutions, including plans for individuals, families, and employers. Their offerings include Medicare and Medicaid plans, dental coverage, and administrative services for small and large groups. Committed to member care, PacificSource emphasizes customer service and provides various resources for health management, including mental health support and wellness programs.

📋 Description

• Supervise and provide leadership to the Claims Audit team • Ensure claims processing meets department and company standards for production and quality • Evaluate team member performance using reports and metrics; identify training needs and support departmental goals • Oversee the Fraud, Waste, and Abuse claim review process and assist with complex claims documentation • Support accurate claims service across medical, dental, vision, self-funded, individual, and COBRA lines • Review and research medical and dental claims and determine coverage based on contracts, provider status, and processing guidelines • Investigate and settle claims issues; relay research and responses for Appeals and Grievances • 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, and strategic/internal committees • Evaluate stop-loss contracts and prepare manual specific, aggregate, and overlapping-contract reporting • Communicate 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 • Oversee the Claims Refunds team and monitor refund collection processes • Assist with hiring, staff development, performance reviews, corrective actions, and terminations • Conduct regular one-on-ones and evaluations • Improve interdepartmental processes using lean methodologies, visual boards, daily huddles, and key performance indicators • Follow PacificSource privacy policy and HIPAA confidentiality and security requirements • Meet department and company performance and attendance expectations; perform other duties as assigned

🎯 Requirements

• Minimum of 4 years of complex claims management experience, including auditing, billing, research, and recovery, with demonstrated leadership capabilities • At least 1 year of supervisory experience required • Experience in self-funded claims administration preferred • Requires high school diploma or equivalent • Thorough understanding of PacificSource products, plan designs, provider relationships and health insurance terminology or the ability to learn • Basic working knowledge of Insurance Division rules and regulations per state • Advanced PC skills including Microsoft Word and Excel • Ability to type using a standard keyboard, operate 10-key pad accurately, multi-line telephone system, and fax machine • Research skills and ability to evaluate claims in order to audit accurately • Advanced skills in medical terminology and CPT/ICD-10 coding • Accountable for the quality and accuracy of documents, files and records used to substantiate stoploss cases • Ability to read and comprehend both written and spoken English • Communicate clearly and effectively • Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive typing/sorting/filing motions, and lift/carry files and business materials • Travel required approximately 5% of the time