Senior Claims Examiner & Quality Lead

Solis-Health-Plans; Florida; On-site; USD 26,000 - 32,000; Full time

Job summary

Solis-Health-Plans in Doral, FL is seeking a supervisor of claims processing to lead the quality and auditing program. You will configure, implement and administer processes to ensure accurate payments and regulatory compliance.

This role requires coordinating with network services, reviewing complex claims, and guiding a team to meet CMS rules and deadlines. Prior experience with Medicare claims and HCPCS/CPT/ICD coding is preferred.

Qualifications

• Strong working knowledge of claims processing standards, CMS claims processing requirements and various Medicare fee schedules.
• Knowledge of automated claims processing systems and complex rules and regulations.
• Follow federal and state regulatory requirements applicable to health plan operations.

Responsibilities

• Configure, implement and administer a robust claims quality and auditing program.
• Establish best practice claims payment methodology based on CMS rules.
• Conduct root cause analysis on systemic issues and form action plans to prevent incorrect payments.
• Coordinate with Network Services and Provider Relations to ensure proper reimbursements.
• Supervise and develop team members to achieve peak performance.

Skills

Claims processing

CMS rules

Medicare fee schedules

Regulatory compliance

Auditing

Job description

Solis-Health-Plans in Doral, FL is seeking a supervisor of claims processing to lead the quality and auditing program. You will configure, implement and administer processes to ensure accurate payments and regulatory compliance.

This role requires coordinating with network services, reviewing complex claims, and guiding a team to meet CMS rules and deadlines. Prior experience with Medicare claims and HCPCS/CPT/ICD coding is preferred.