Lead Claims Specialist - Claims Processing

Manage claims internal audit functions, including audit processes for adjudicated claims and encounters, while monitoring check run processes for accuracy. Develop policies and procedures for periodic claims audits to ensure compliance with affiliated health plans, client groups, and administrative contractual agreements. Design, plan, direct, and implement claims training programs for the organization, adapting to changes in policies, procedures, and technologies. Maintain familiarity with applicable State and Federal claim payment and denial timeliness legislation, Timeliness Compliance rules, and the Provider Dispute Resolution tracking mechanism (AB1455). Requires five years of professional and facility claims processing experience.