Lead Analyst, Claims

Tpa Claiming Lead

Public Consulting Group LLC (PCG) is a leading public sector solutions implementation and operations improvement firm that partners with health, education, and human services agencies to improve lives. Founded in 1986, PCG employs approximately 2,000 professionals throughout the U.S.—all committed to delivering solutions that change lives for the better. The firm is a member of a family of companies with experience in all 50 states, and clients in three Canadian provinces and Europe. PCG offers clients a multidisciplinary approach to meet challenges, pursue opportunities, and serve constituents across the public sector.

The TPA Claiming Lead will lead all efforts of the TPA Claiming Operations Team within the School-Based Services (SBS) Center of Excellence (COE) Operations functional area. This position will direct claims management for TPA models. This role will take ownership for fidelity, efficiency, and optimization in our TPA claiming work. This role must effectively integrate capabilities in claims management, data management, and project management to promote strong collaboration with the Client Success, Technology, and Program Integrity functional areas to execute contractual obligations. The TPA Claiming Lead will also work with Regional Leadership to understand state and local environments, allowing them to effectively implement and expand the PCG claiming operations program. The ideal candidate should be reflective and thoughtful about PCG's processes and ready to build and support a team that will develop and implement a consistent, efficient claiming program with capacity for scalable growth and adaptation to meet evolving policies and client needs.

Duties and Responsibilities

• Analyzes and reviews claims for accuracy, completeness and eligibility.
• Provides leadership, supervision and coaching to junior department staff.
• Prepares and submits claims data for multiple clients within multiple states.
• Analyzes the development of claims assigned at each level of the adjudication process.
• Provides support and give direction to less experienced staff
• Evaluate medical records and apply evidence to each case.
• Provides monthly reporting statistics.
• Ensures adherence to claim timeliness and accuracy performance standards.
• Prepares for and participate in various meetings, including status reports, process improvement meetings and meetings related to collection of required data.
• Conducts policy and other research.
• Assists with quality control projects, including case reviews to ensure the integrity of claim methodology and eligibility determinations.
• Assists with preparation of other written reports and materials for clients.
• Assists in administration of time studies and operation of help desk lines.
• Trains others on the function of analyzing claims.

Leadership & Oversight

• Understand Federal, State, and local Medicaid policies as they pertain to our Education clients and our systems for processing and submitting claims
• Seek continuous improvement throughout the service/claim adjudication journey
• Represent the TPA team as member of SBS COE leadership team, balancing FFS team needs with broader COE initiatives and efforts  
• Act as an escalation point of contact for TPA Claiming Operations
• Manage budget and resource leveling for TPA Claiming Operations in support of building PCG's reputation as a trusted partner 
• Solicit feedback from members of the TPA Claiming Operations Team and champion initiatives that address the evolving needs of our clients
• Establish best practice models and structures for claims processing and adjudication, including coordinating involvement from other functional areas (e.g., creation of new technical functions)

Skills for Success:

• Assists with leading daily and weekly TPA claiming functions
• Manages/Oversees the Health-aide prior authorization process
• Coordinates and communicates risk and issue escalations
• Robust data skills, secure data handling, and understanding of data fidelity best practices
• Data analysis skills, especially as it relates to optimization opportunities  
• Detailed understanding of Medicaid policy and operations
• Effective communication skills (presentation, facilitation, and written) 
• Ability to quickly understand and implement new technical and policy requirements
• Collaboration skills (with peers, staff, and leadership) and propensity for relationship building 
• Team building, staff development, and coaching skills  
• Leadership skills, including the ability to be decisive, consistent, transparent, and open to feedback  
• Commitment to living and promoting PCG's values of impact, community, passion and entrepreneurial spirit; and
• Professional maturity and ability to put the best interests of the client and PCG above self-interest  

Required Skills

• Ability to evaluate, coordinate and perform a complex set of planning, development and administrative tasks.
• Ability to build and maintain working relationships with federal, state and county agency staff.
• Strong Microsoft application skills.
• Ability to work with a large volume of claims and effectively prioritize the workload.
• Excellent organizational, oral presentation and written communication skills.
• Strong analytical skills, including the ability to analyze and organize data.
• Existing knowledge or experience with state government, health insurance payment systems (particularly Medicaid), and/or cost accounting are highly advantageous.
• Knowledge and understanding of appropriate laws and regulations and applicable government agencies
• Overtime and travel might be needed at times.

Qualifications

• Bachelor's degree in a relevant field is preferred
• 6+ years of relevant claiming experience is required. Previous leadership experience is preferred.

Working Conditions

• Office Setting- Remote

Compensation:

Compensation for roles at Public Consulting Group varies depending on a wide array of factors including, but not limited to, the specific office location, role, skill set, and level of experience. As required by applicable law, PCG provides a reasonable range of compensation for this role. In addition, PCG provides a range of benefits for this role, including medical and dental care benefits, 401k, PTO, parental leave, bereavement leave.

Range: $68,800 - $94,000

EEO Statement:

Public Consulting Group is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion. We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences. At PCG, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications. We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law. PCG will not tolerate discrimination or harassment based on any of these characteristics. PCG believes in health, equality, and prosperity for everyone so we can succeed in changing the ways the public sector, including health, education, technology and human services industries, work.