This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more.

Role Description

The Eligibility and Recovery Claims Lead will possess advanced knowledge of healthcare eligibility, healthcare claims, medical terminology, eligibility validation practices, Coordination of Benefits and Third-Party Liability (COB/TPL). This position will also support new client implementations and existing programs with detailed analysis of all claiming operations, including but not limited to outgoing and incoming healthcare EDI transactions.

• Leverage knowledge and expertise in COB and TPL to review healthcare claims and client data.
• Review and analyze client data to identify trends, patterns, and impacts across various products.
• Assist technical and business leads with requirements gathering, documentation, and project management for new implementations and existing program changes.
• Conduct a variety of data analysis for intelligent insights using subject matter knowledge, independent judgment, and analytical expertise.
• Develop custom queries and reporting, conduct research, analyze trends and activities, and present data and findings based on business needs to identify opportunities and root causes of issues.
• Collaborate with leadership to provide effective and detailed analysis required for optimal business operations.
• Maintain a strong team through meetings, training, coaching, mentoring, and other development techniques.
• Follow and comply with company, departmental, and client program policies, processes, and procedures.
• Utilize resources to ensure compliance with client requirements, HIPAA, and applicable federal or state regulations.
• Successfully complete, retain, apply, and adhere to content in required training as assigned.
• Complete required processes to obtain client-required clearances and successfully pass background and/or drug screening as a condition of employment.
• Demonstrate Performant core values in performance of job duties and all interactions.
• Correct areas of deficiency and oversight received from quality reviews and/or management.
• Other duties as assigned.

Qualifications

• Knowledge of and ability to work with large volumes of healthcare claims data.
• Knowledge of healthcare medical and pharmacy claims.
• Experience with Medicaid / Medicare / Other TPL business models and products.
• Knowledge of requirements gathering, ETL processing, and data matching.
• Strong system skills with ability to quickly develop expertise in new systems and applications.
• Advanced skills in Excel, Access, and/or other data analysis applications.
• Proficient SQL skills to query and test.
• Advanced knowledge of X12 EDI Transactions, including but not limited to 270/271, 277, 837, 835, 834.
• Professional verbal and written communication with good presentation skills.
• Able to work independently and meet deadlines with minimal supervision.
• Strong problem-solving and communication (written and oral) skills.
• Ability to produce results and maintain a positive attitude in a fast-paced, dynamic environment.
• Self-motivated and thrives in a fast-paced business operations department performing multiple tasks cohesively, with keen attention to detail.

Requirements

• Bachelor’s degree in relevant field, or equivalent combination of education and experience may be considered.
• 7+ years relevant experience working with healthcare claims data.
• 3+ years management or supervisory experience.
• Advanced knowledge and experience with healthcare claim operations, Coordination of Benefits, and Third Party Liability.

Benefits

• Medical, dental, vision, HSA/FSA options.
• Life insurance coverage.
• 401(k) savings plans.
• Family/parental leave.
• Paid holidays.
• Paid time off annually.