Team Leader - Direct Billing Claims

Job purpose:

Leading the claims processing team. Ensuring the smooth and efficient processing of claims, maximizing reimbursement, and maintaining compliance with regulations and policies.

Key Responsibilities

• Team Management: The team leader is responsible for overseeing and managing a team of claims processors who handle direct billing claims. TL involves providing guidance, direction, and support to the team members, monitoring their performance, ensuring that the team meets their goals and targets.
• Claims Processing: The team leader is involved in the processing of direct billing claims. They may review complex or high-value claims, taking decision on claims settlements, resolve any issues or disputes that arise during the claims process. TL ensure that claims are processed accurately, efficiently, and in compliance with company policies and insurance regulations.
• Training and development: The team leader is responsible for training new team members and providing ongoing training and development opportunities to existing staff. TLs ensuring that team members are equipped with the necessary knowledge and skills to handle direct billing claims effectively. This may involve organizing training sessions, preparing training materials, and providing feedback and coaching team members.
• Performance Monitoring: The team leader is responsible for tracking and monitoring the performance of the direct billing claims team, by regular performance evaluation, and providing feedback to the team members on their individual performance. Identify areas for improvement and implement tools to enhance team productivity, accuracy.
• Process Improvement: Continuous process improvement is essential in claims process. TL identifies opportunities to streamlines processes, enhance efficiency, and reduce errors or delays in claim processing. TLs coordinate with the other departments and stakeholders to implement improvements.
• Reporting and Analysis: The team leader prepares reports and analyzes data related to the team’s performance, claim trends. TLs provide regular updates to their line manager, highlighting areas of concern or improvement opportunities, and using data analysis to identify patterns, make informed decisions, and implement ways to optimize claims handling processes.
• Compliance and Quality Assurance: Insurance companies operate under strict regulatory guidelines, and adherence to these regulations is crucial. The TL ensures that the direct billing claims team complies with all applicable laws, regulations, and industry standards. They may conduct quality assurance audits, perform internal reviews, and implement corrective actions to address any identified compliance gaps or quality issues.

Operational & technical responsibilities

• Oversee the claims processing workflow. Coordinating the workflow within the direct billing claims department. Including assigning tasks and priorities, monitoring progress, and ensuring efficient and timely process of claims.
• Ensure the accuracy and quality of claims processing within the team. Conducting regular audits and quality checks, providing feedback, and coaching to team members, and implementing corrective actions as needed.
• Team leader should have a strong understanding of the technical aspects of direct billing claims processing. This includes knowledge of insurance policies, billing codes, payment systems.
• Evaluating claims based on policy terms and conditions, medical necessity, and coding guidelines.
• Involve in reporting potentially fraudulent or suspicious claims. Collaborate with the FWA, and NW departments to gather evidence and raise to the line manager to take appropriate action.
• Work with NW team to maintain accurate and up-to-date information on contracted healthcare providers & present the monthly statistics on submissions and claim figures. Ensuring provider claims are processed correctly and that providers are reimbursed according to negotiated rates.
• Evaluate and review claims rejections. Review rejected claims, identify reasons for rejections to ensure the reasons of rejections are genuine denials, and could be accepted by the providers to reduce the resubmission and reconciliation claims.