Coordinates various claim projects and assists management by providing support, communicating instructional and operational information with the ability to interface with internal staff and mid-upper management professionals. Utilizes understanding and application of cost containment techniques when vendor partnerships are utilized to reduce overall cost of claims while applying plan or line of business specific processing rules. This would include but not be limited to forensic reviews, reprici... more details
Team Lead, Claims
SummaCare - 1200 E Market St, Akron, OH
Full-Time / 40 Hours / Days
Remote After Training
SummaCare is a Summa Health entity that offers health insurance in northern Ohio. As a regional, provider-owned health plan, SummaCare is based in Akron, Ohio, and provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating for 2024 by the Centers for Medicare and Medicaid Services (CMS). Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits.
Summary:
Coordinates various claim projects and assists management by providing support, communicating instructional and operational information with the ability to interface with internal staff and mid-upper management professionals. Utilizes understanding and application of cost containment techniques when vendor partnerships are utilized to reduce overall cost of claims while applying plan or line of business specific processing rules. This would include but not be limited to forensic reviews, repricing reconciliations, case agreement management including review of related authorizations and claims. Works across departments to reconcile stop loss and reinsurance claimants. Assists the department with mentorship and training.
Formal Education Required:
-High School Diploma or equivalent
Experience & Training Required:
-Five (5) years experience in health insurance claims processing at a senior level, claims training, claims auditing, and/or project management and facilitating meetings
Other Skills, Competencies and Qualifications:
-Word and Excel and Access at an intermediate level. Must achieve passing score on test administered by Human Resources.
-MS-windows based computer environment
-Skilled in medical terminology, CPT, HCPCs, ICD-10, DRG, ASC, ASG coding
-Understanding of professional (CMS1500) and institutional (UB-04) claim types
-Health claims processing knowledge
-Independent judgment, decision-making, research and analytical skills
Level of Physical Demands:
-Sit for prolonged periods of time
-Bend, stop and stretch
-Lift up to 20 pounds
-Manual dexterity to operate computer, phone and standard office machines
$23.51/hr - $28.21/hr
The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical.
