Complex Claims Lead

NHS Group; El Paso (TX); On-site; USD 54,000 - 78,000; Full time

Job summary

Assured Benefits Administrators, Inc. in El Paso, TX seeks a Complex Claims Lead to supervise and process complex healthcare claims, ensuring accuracy and compliance.

You will oversee year-end processing, adjustments, coordination of benefits, subrogation and high-dollar claims, Medicaid claims and appeals, plus hospital audits and related reporting. Requires an associate degree and 1–3 years in claims processing with strong attention to detail and analytical problem solving.

Qualifications

• Associate degree preferred; equivalent combination of education and experience considered.
• 1–3 years of claims processing experience.
• Strong attention to detail and quality assurance in claims processing.
• Analytical and problem-solving skills to identify root causes.

Responsibilities

• Year-End Processing: Oversee and facilitate year-end processing activities to ensure timely closure of claims records.
• Adjustments Management: Process adjustments to claims with proper documentation and policy adherence.
• Coordination of Benefits: Manage coordination of benefits for claims.
• Subrogation and High-Dollar Claims: Handle subrogation and high-dollar claims with careful review.
• Medicaid Claims and Complex Appeals: Process Medicaid claims and assist in handling complex appeals.
• Hospital Audits: Conduct hospital audits to ensure compliance with agreements and regulations.
• Case Management Reports: Analyze case management reports and ensure correct filing for members.

Skills

Claims processing

Attention to detail

Analytical thinking

Problem-solving

Education

Associate degree

Job description

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Complex Claims Lead

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

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