Complex Claims Lead

Assured Benefits Administrators; El Paso (TX); On-site; USD 42,000 - 64,000; Full time

Job summary

Assured Benefits Administrators, Inc. (ABA) is a leading TPA providing healthcare administration solutions across the United States. We are looking for a Claims Processor to ensure accurate year-end processing, handle adjustments, and coordinate benefits.

The role covers Medicaid claims, subrogation, and high-dollar claims, with hospital audits and complex appeals. Ideal candidates have 1–3 years of claims experience and strong attention to detail.

Qualifications

• Associate degree preferred; equivalent combination of education and experience considered.
• Minimum 1–3 years of experience in claims processing.
• Strong understanding of claims processing procedures and medical terminology.
• Detail-oriented with emphasis on accuracy and quality assurance.
• Analytical and problem-solving abilities; able to handle escalated issues.
• Ability to make sound decisions under pressure.

Responsibilities

• Year-End Processing: Oversee year-end processing to close claims records.
• Adjustments: Process adjustments with proper documentation.
• Coordination of Benefits: Manage benefits coordination for claims.
• Subrogation and High-Dollar Claims: Handle complex subrogation/high-dollar cases.
• Medicaid Claims and Complex Appeals: Process Medicaid claims and assist appeals.
• Hospital Audits: Conduct audits to ensure compliance with agreements and regulations.
• Case Management Reports: Analyze reports and file to the correct member.

Skills

Claims processing

Medical terminology

Insurance policies

Data accuracy

Analytical skills

Education

Associate degree

Job description

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.
• 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

None

The noise level in the work environment is usually low to moderate.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions. While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers, handle or feel objects, tools, or controls. The employee is occasionally required to stand, walk, sit, and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, and the ability to adjust focus.