Medicare Claims Examiner Team Lead

Job Description

Job Description

Job Summary :

The Claim Examiner Team Lead is a key resource for the Claim Examiner team, leveraging advanced expertise in claim adjudication, payment integrity and regulatory compliance. This position does not include direct supervisory responsibilities or formal performance reviews. Instead, the Team Lead provides support, coaching, and technical guidance to claim examiners, ensuring accuracy, efficiency, and adherence to CMS and company standards. Acting as a mentor, process improvement lead, and operational reviewer, the Team Lead drives continuous improvement, supports fraud, waste and abuse (FWA) prevention initiatives and collaborates with cross-functional teams to optimize claims processes and professional development.

Key Responsibilities :

Team Leadership and Enablement

• Provide direction, mentorship, and technical support for Claim Examiners, fostering a collaborative and high-performance environment.
• Act as the primary resource for escalated claims and technical questions, offering expert advice and facilitating team learning.
• Contribute to the development and delivery of training materials and workshops, supporting ongoing professional development.
• Lead and support onboarding of new Claim Examiners, ensuring effective orientation to claims processes, company policies, and regulatory requirements.
• Serve as a resource for new team members during their initial training period helping them integrate into the team and build foundation skills.

Claim Adjudication and Payment Integrity

Fraud, Wast, and Abuse (FWA) Prevention

Regulatory Compliance and Quality Assurance

Claim Edit Logic Review and Collaboration

Process Improvement and Operational Excellence

Stakeholder Collaboration and Enablement

Qualifications : Experience :

Certifications :

Skills :

Technical and Analytical :

Communication and Collaboration :

Quality and Process Improvement

Problem Solving and Initiative :

Work Environment / Physical Requirements :

The work environment is a standard office setting with typical office equipment. This role involves professional collaboration with colleagues and clients. Responsibilities may involve extended periods of sitting, occasional walking between departments or meeting rooms, and periodic standing, reaching, stooping, and lifting office items weighing up to 25 pounds.