Medical Coding Quality Team Lead

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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.
Supervise and provide leadership to the Claims Audit team, ensuring adherence to company policies, procedures, and workflows across lines of business. Manage claims production and quality to meet or exceed company standards. Resolve adjudication issues, including additional payments and recoveries. Collaborate with Grievance and Appeals to research and determine appropriate claims outcomes. Responsible for hiring, training, coaching, and evaluating team performance. Demonstrate effective leadership by fostering individual growth, team collaboration, innovation, and commitment to organizational goals. Essential Responsibilities:

- Provide supervision, coaching, training, and leadership to assigned staff. Ensure claims processing meets department and company standards for production and quality.

- Evaluate team member performance using reports and metrics to identify training needs and support departmental goals.

- Oversee the Fraud, Waste, and Abuse claim review process. Assist with complex claims and documentation to identify potential fraud in collaboration with the Compliance team.

- Support the team in delivering exceptional claims service across all lines (medical, dental, vision, self-funded, individual, COBRA, etc.), ensuring accurate benefit interpretation.

- Oversee and assist with review, research of medical claims, and determine coverage based on contract, provider status and claims processing guidelines. Investigate and settle claims issues as needed. Relay information for dispute resolution, including research and response for Appeals and Grievances, to appropriate departments and personnel. Claims to include Dental.

- Communicate business process and procedural changes promptly to team members.

- Collaborate with the Training Coordinator on initial and ongoing education for staff.

- Oversee and assist responses to inquiries via mail or email, ensuring quality service and preparing reports or correspondence as needed.

- Participate in interoffice committees and share relevant updates with the team.

- Engage in Claims leadership peer group to promote cross-team communication, collaboration, and process efficiency with results in consistent, quality claims processing outcomes.

- Evaluate stop-loss contracts to ensure proper administration and prevent aggregate violations.

- Maintain open communication with Account Managers, agents, and carriers regarding stoploss status. Respond to inquiries regarding stoploss accounting and administration. Create manual reporting for internal and external recipients. Create manual Specific and Aggregate stoploss reporting, accounting for changes made based on claims analysis. Produce manual reporting to account for claims applying to overlapping contracts, claims applying to an aggregating-specific deductible or contracts split between a current and prior group number or third-party administrator.

- Document and escalate claims processing or system configuration issues to the Claims Manager.

- Provide expert-level education and support to other departments on billing/coding, medical records review, and claims processing.

- Collaborate with Grievance and Appeals to determine appropr