Claims Examiner Team Leader

Role Description

The Claims Examiner Team Leader is responsible for leading and managing a team of claims examiners to ensure accurate, compliant, and timely processing of medical claims. This role serves as a critical bridge between frontline operations and leadership, driving performance against SLAs, quality standards, and productivity targets. The Team Lead is accountable for team performance, coaching and development, and continuous process improvement while ensuring adherence to Medicare regulations and CMS guidelines.

Key Responsibilities

• Team Leadership & Performance Management
  • Lead, supervise, and support a team of 15–20+ claims examiners.
  • Provide ongoing coaching, mentoring, and real-time feedback to improve quality, accuracy, and productivity.
  • Conduct regular performance evaluations and goal setting.
  • Foster a culture of accountability, engagement, integrity, and continuous improvement.
• Claims Operations Oversight
  • Oversee day-to-day medical claims processing for professional, facility, adjustments, corrected and adjustment claims.
  • Ensure compliance with Medicare requirements, CMS guidelines, client policies, and Imagenet standards.
  • Monitor and manage service level agreements (SLAs), turnaround times, and production.
• Quality Assurance & Compliance
  • Apply deep working knowledge of CMS regulations, Medicare auditing standards, and payer guidelines.
  • Review claims and audit results to identify trends, root causes, and training opportunities.
  • Ensure consistent application of quality standards by partnering with other team leads to reduce error rates across the team.
• Reporting, Metrics & Business Reviews
  • Analyze and manage key performance indicators including quality scores, error rates, productivity, attendance, and rework.
  • Prepare and present operational and business reviews using accurate data and client feedback.
  • Identify operational risks, performance gaps, and improvement opportunities and escalate as appropriate.
• Process Improvement & Cross-Functional Collaboration
  • Identify process inefficiencies and implement improvement strategies to increase accuracy, efficiency, and cost effectiveness.
  • Assist with QA, Training, IT, and Operations leadership to resolve technical or workflow issues.
  • Support implementation of new policies, tools, workflows, and client requirements.
• Communication & Client Support
  • Maintain clear, timely communication with leadership regarding team performance and operational risks.
  • Address employee concerns and team conflicts professionally and promptly.
  • Escalate client issues or compliance concerns to management immediately when identified.
• Engagement & Recognition
  • Recognize and reward strong performance and team achievements.
  • Promote teamwork, professionalism, and a positive attitude within the team.

Measures of Success / Key Performance Indicators

• Claims quality and audit results both for personal performance and team performance.
• Error rates and rework reduction both for personal performance and team performance.
• Productivity (claims per day/hour) both for personal performance and team performance.
• Turnaround time / time to completion both for personal performance and team performance.
• Compliance with CMS, Medicare, Medi-Cal, and client guidelines.
• Attendance and reliability both for yourself and your team.
• Client satisfaction and assessment outcomes.
• Team engagement, coachability, and retention.
• Cost efficiency and margin impact.

Qualifications

• Min. 5 years of experience processing easy, moderate, and complex medical claims.
• 2+ years in a leadership role within claims or healthcare operations.
• Strong experience with Medicare and Medi-Cal claims, including a working knowledge of CMS guidelines and regulatory requirements.
• Prior quality assurance and training experience with demonstrated ability to identify trends.
• Previous experience leading, coaching, or mentoring teams in a claims or healthcare operations environment.
• Strong analytical skills with the ability to interpret performance data and KPIs.
• Excellent communication, organizational, and decision-making skills.
• High attention to detail and commitment to accuracy, compliance, and operational excellence.

Benefits

• Remote work offered.
• Equipment provided.
• Paid training to set you up for success.
• Comprehensive benefits: Medical, Dental, Vision, Life, HSA, 401(k).
• Paid Time Off (PTO).
• 7 paid holidays.
• A supportive team and a company that values internal growth.

Company Description

Imagenet is a leading provider of back-office support technology and tech-enabled outsourced services to healthcare plans nationwide. Imagenet provides claims processing services, including digital transformation, claims adjudication and member and provider engagement services, acting as a mission-critical partner to these plans in enhancing engagement and satisfaction with plans’ members and providers.