Claims Team Lead, NCM

The Claims Team Lead – Medical Management, is responsible for assisting with the oversight of a team of medical professionals. In this role, the Claims Team Lead – Medical Management will be responsible for department Quality Assurance, production, and workflow management. They will work closely with the Nursing Supervisor and Nursing Team Lead to ensure compliance standards are met. Responsibilities Monitor workflows and incoming treatment plan volume for a team of medical professionals to ensure regulatory deadlines and performance goals are met. Oversee Medical Management Compliance, evaluation of New Jersey specific regulations, training of staff, and evaluation of results to ensure the operation complies with all state requirements. Review and evaluate decisions made by Nurse Case Representatives and verify decisions made are within the standards of the Company’s Decision Point Review Plan and New Jersey AICRA requirements. Document case activities and action plans in a SOAP note format. Evaluate and identify workflow trends, quality assurance opportunities, and/or key issues, analyze available data and recommend corrective action. Provide overall support to the Medical Claims Department, effectively answer questions, handle customer / provider inquiry calls and assess claims decisions made. Assist in the development, review and implementation of policies and procedures to ensure consistency, quality and efficiency within the unit. Work closely with Medical Directors and the treating providers to assess, implement, and evaluate medical treatment provided to the injured person. Review medical expense payments in accordance with Company claim guidelines for prompt payment processing. Work closely with the Nursing Supervisor to help manage and delegate the day-to-day operation of the unit. Assist the Nursing Supervisor with monthly/quarterly reports as needed. Review all Medical Management reports and analyze potential for change/improvement. Foster an environment that is team oriented, customer responsive, and quality driven. Handle project work at request of the PIP Directors and/or Supervisor. Other administrative tasks as needed Qualifications 5+ years of Medical Claim or Medical Administrative experience PIP experience, knowledge of DOBI Care Path Guidelines. RN or LPN preferred but not required. Experience with insurance fraud identification. Functional knowledge of medical terminology and anatomy. Knowledge of ICD and CPT coding is preferred. Thorough understanding of the New Jersey AICRA regulations. Must have excellent written and verbal communication, analytics, and organizational skills. Strong critical thinking skills, the ability to exercise independent judgment and the ability to solve problems effectively. Demonstrated leadership skills with the ability to motivate, coach, and influence team performance and operational goals. Prior supervisory experience is a plus but not required. Possess a strong working knowledge of Excel, including the development of charts and visual data for analytics. Ability to build reports, pivot tables, and utilize Tableau is a plus. An ability to multi-task and work independently Salary Range The pay range for this position is $83,000 to $107,000 annually. Actual compensation will vary based on multiple factors, including employee knowledge and experience, role scope, business needs, geographical location, and internal equity. Location(s) 581 Main Street, Woodbridge , New Jersey 07095 , United States EEO Statement Plymouth Rock is committed to a policy of non-discrimination and equal opportunity for all qualified applicants and employees without regard to race, color, religion, gender, sexual orientation, age, national origin, ancestry or disability. #J-18808-Ljbffr RadNet, Inc.