Complex Claims Lead

Independent Medical Systems, Inc.; El Paso (TX); On-site; USD 60,000 - 80,000; Full time

Job summary

Assured Benefits Administrators, Inc. is seeking a Complex Claims Lead in El Paso, TX. The role focuses on processing and closing claims with accuracy, managing year-end tasks, COB, subrogation, Medicaid claims, appeals, and hospital audits.

The ideal candidate has 1–3 years in claims processing, strong knowledge of medical terminology and policies, and proven analytical and escalation-handling abilities to ensure timely resolutions and high-quality outcomes.

Qualifications

• 1–3 years of experience in claims processing or related field.
• Strong understanding of claims processing procedures and medical terminology.
• Attention to detail and quality assurance in claims processing.
• Analytical and problem-solving skills to identify root causes and solutions.
• Experience handling escalated issues and making sound decisions under pressure.

Responsibilities

• Year-End Processing: oversee year-end processing activities for claims closure.
• Adjustments: process adjustments with proper documentation.
• Coordination of Benefits: manage COB for claims.
• Subrogation and High-Dollar Claims: handle complex cases with accuracy.
• Medicaid Claims and Complex Appeals: process Medicaid claims and assist with appeals.
• Hospital Audits: conduct audits to ensure compliance with agreements and regs.
• Case Management Reports: analyze reports and file to the correct member.

Skills

Claims processing

Attention to detail

Analytical thinking

Problem solving

Escalation handling

Education

Associate degree

Job description

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Complex Claims Lead

OP-Claims Regular Full Time Clerical El Paso, TX, US

3 days ago Requisition ID: 1834

ABOUT US

Assured Benefits Administrators, Inc. (ABA) is a full-service third-party administrator, or TPA, providing flexible and fully integrated healthcare administration and management solutions across the United States since 1985. We are part of an international healthcare group with more than 35 years of industry experience, and we’re fully integrated with our long-term partners, who are recognized as industry leaders.

ABA is a certified “Great Place to Work”, united by a single mission: standing with members through every moment and milestone in their healthcare journey. With decades of industry experience and a team driven by passion, integrity, and excellence, ABA is committed to delivering connected, transparent, and innovative healthcare solutions to employers and members across the United States.

POSITION SUMMARY

As a Claims Processor, you will play a pivotal role in ensuring the efficiency and accuracy of claims processing within our organization. Your responsibilities will encompass a wide range of tasks, including year-end processing, managing adjustments, coordinating benefits, handling subrogation and high-dollar claims, processing Medicaid claims and complex appeals, and engaging in hospital audits.

ESSENTIAL DUTIES AND RESPONSIBILITIES

The essential functions include, but are not limited to the following:

• Year-End Processing: Oversee and facilitate the year-end processing activities to ensure timely and accurate closure of claims records.
• Adjustments Management: Process adjustments to claims as needed, ensuring proper documentation and adherence to company policies and procedures.
• Coordination of Benefits: Manage coordination of benefits for claims.
• Subrogation and High-Dollar Claims: Handle subrogation claims and high-dollar claims, applying sound judgment and attention to detail in reviewing and processing these complex cases.
• Medicaid Claims and Complex Appeals: Process Medicaid claims and assist in handling complex appeals, demonstrating a thorough understanding of Medicaid regulations and procedures.
• Hospital Audits: Conduct hospital audits to ensure compliance with contractual agreements and regulatory requirements.
• Case Management Reports: Analyze case management reports and make sure they are filed to the correct member.

MINIMUM QUALIFICATIONS (KNOWLEDGE, SKILLS, AND ABILITIES)

Associate degree preferred; equivalent combination of education and experience considered.

• Minimum of 1-3 years of experience in claims processing or related field.
• Strong understanding of claims processing procedures, including familiarity with medical terminology and insurance policies
• Highly detail-oriented with a focus on accuracy and quality assurance in claims processing
• Strong analytical and problem-solving skills with the ability to identify root causes and develop solutions.
• Experience handling escalated issues and making sound decisions under pressure.

OTHER DETAILS

Supervisory Responsibilities