TL-Claims HC

Job Summary

This hybrid role focuses on transactional leadership in health care claims operations for both provider and payer functions ensuring precise HIPAA compliant claims adjudication during night shifts. The team lead guides a small claims team resolves complex claim scenarios improves adjudication quality and supports service goals for global health plan clients.

Responsibilities

• Guide a team of claims analysts in day to day claims adjudication activities to ensure timely and accurate processing of health care claims during night shifts in a hybrid work environment.
• Oversee adjudication of complex provider and payer claims while applying HIPAA regulations and benefit plan rules to minimize financial leakage and processing errors.
• Drive continuous improvement in end to end claims workflows by analyzing trends in rework denials and customer escalations and by implementing targeted process refinements.
• Monitor individual and team performance metrics such as turnaround time financial accuracy procedural accuracy and inventory aging while taking corrective actions when thresholds are at risk.
• Coordinate closely with quality audit and training partners to address recurring defects in claims adjudication and to update job aids based on policy or regulatory changes.
• Provide expert guidance on provider contracting reimbursement methodologies coordination of benefits and subrogation scenarios to ensure consistent application of payer business rules.
• Escalate systemic issues in claims platforms or upstream enrollment and billing processes and collaborate with technology and operations stakeholders to design sustainable fixes.
• Conduct regular night shift huddles to communicate daily priorities policy updates and client expectations fostering transparent communication across the claims team.
• Respond to claim inquiries from internal partners and client representatives by performing root cause analysis and presenting clear data backed resolutions that enhance stakeholder trust.
• Review claim samples for HIPAA compliance and privacy controls and ensure that all team procedures align with enterprise information security standards.
• Prepare concise operational reports and dashboards summarizing work volumes productivity service level adherence and defect trends for supervisor and client review.
• Support knowledge management by documenting complex adjudication scenarios exception handling steps and best practices so new team members can reach proficiency faster.
• Align daily work priorities with broader organizational objectives such as cost containment regulatory compliance and member and provider satisfaction with a clear focus on social impact of accurate claims outcomes.
  
  

Qualifications

• Demonstrate proven experience in health care claims adjudication with substantial exposure to both provider and payer environments across a minimum of four years.
• Apply deep understanding of HIPAA regulations including privacy and security requirements to all aspects of claims review and documentation activities.
• Exhibit advanced knowledge of benefit plan structures coding concepts coordination of benefits and medical policy interpretation in order to adjudicate complex claims scenarios.
• Utilize strong analytical and spreadsheet skills to interpret claims data identify anomaly patterns and recommend practical remediation steps that reduce recurrence.
• Communicate clearly and professionally in written and spoken form to interact with cross functional stakeholders and to document decisions in an auditable manner.
• Adapt effectively to hybrid work settings and night shift schedules while maintaining reliability accountability and consistent productivity standards.
• Leverage prior experience in guiding or mentoring small operational teams to coordinate work allocation provide feedback and uphold a culture of accuracy and compliance.