● Supervise day-to-day operations of a medical claims processing team responsible for reviewing, analyzing, and adjudicating professional, facility, and complex claim types.
● Oversee workload distribution, staffing coverage, productivity expectations, and performance monitoring to meet contractual timeliness and accuracy standards.
● Provide coaching, mentoring, and training on claims rules, system changes, Program policy updates, and adjudication procedures to strengthen team expertise.
● Conduct quality reviews, identify error trends, and implement process improvements to enhance accuracy, compliance, and operational efficiency.
● Serve as a subject matter resource for escalations, benefit interpretations, complex claims, and policy questions.
● Ensure proper claim documentation, consistent policy application, and audit-ready recordkeeping across all adjudication actions.
● Collaborate with Medical Policy, Utilization Management, Finance, Provider Services, and Compliance teams to resolve claim discrepancies, coding issues, or benefit concerns.
● Track metrics and prepare operational reports related to productivity, quality, timeliness, inventory aging, and issue trends.
● Support testing and validation of system updates, benefit modifications, policy changes, or new workflows.
● Contribute to hiring, onboarding, performance evaluations, and ongoing development of claims processing staff.
● Ensure compliance with HIPAA and program confidentiality requirements.
● Participate in operational redesign and continuous improvement initiatives to optimize claims processing outcomes.