Team Lead - Healthcare Claims Adjudication

Job Overview

This position entails a hybrid night shift role concentrating on the review and adjudication of complex health care claims. The incumbent ensures strict compliance with HIPAA regulations while aligning with payer and provider policies to facilitate fair and timely claim resolutions. The role demands thorough claims analysis, discrepancy resolution, and cross-functional collaboration to enhance the accuracy and speed of claims processing.

Key Responsibilities

• Oversee the complete claims adjudication lifecycle by applying policy guidelines, payer rules, and provider contracts to guarantee accurate and prompt payment decisions.
• Evaluate intricate claim cases with focus on medical policies, benefit structures, and coding specifics to minimize financial losses and reduce rework.
• Confirm the integrity of claims data by verifying member eligibility, coverage thresholds, and coordination of benefits to avoid errors and claim denials.
• Ensure all claims handling strictly complies with HIPAA privacy and security mandates to safeguard sensitive member and provider details.
• Investigate adjudication exceptions and pending claims to identify root causes and propose targeted process enhancements that improve operational efficiency.
• Collaborate with payer operations to clarify benefit interpretation, policy amendments, and reimbursement frameworks impacting claim decisions.
• Work closely with provider support teams to address claim disputes, coding inquiries, and payment discrepancies professionally and solution-oriented.
• Maintain detailed documentation of claim decisions, rationales, and adjustments within the claims system to support compliance and audit processes.
• Utilize claims processing tools and reference materials to interpret contract terms, fee schedules, and medical policies ensuring consistent adjudication.
• Contribute to quality audits and compliance verifications by supplying accurate case insights, trend analyses, and recommending corrective actions for recurring issues.
• Participate in continuous improvement programs by reporting frontline observations of payer and provider challenges to enhance member and partner satisfaction.
• Mentor junior claim analysts by imparting best practices in claims adjudication, HIPAA compliance, and dispute resolution while fulfilling individual contributor duties.
• Align daily responsibilities with organizational objectives by prioritizing claims affecting critical regulatory, service level, and financial accuracy metrics.

Qualifications

• Possession of a bachelor's degree or equivalent education in healthcare administration, business, or a related analytical discipline supporting claims operations.
• At least four years of practical experience in healthcare claims adjudication, involving payer and provider environments and relevant platforms.
• Comprehensive knowledge of HIPAA regulations including privacy, security, and transaction standards consistently applied in daily claim handling.
• Demonstrated skill in interpreting payer policies, provider contracts, explanations of benefits, and coding standards to resolve complex claims independently.
• Strong analytical and problem-solving abilities utilizing data from high-volume claims to detect denial patterns, rework, and exceptions.
• Effective verbal and written communication skills for interacting with payer teams, provider offices, and internal departments regarding claim outcomes and next steps.
• Willingness and ability to operate successfully in a hybrid work setting on a permanent night shift schedule, ensuring high productivity, accuracy, and peer collaboration across locations and time zones.