Job Description

The Claims Team Lead – Medical Management, is responsible for assisting with the oversight of a team of medical professionals. In this role, the Claims Team Lead – Medical Management will be responsible for department Quality Assurance, production, and workflow management. They will work closely with the Nursing Supervisor and Nursing Team Lead to ensure compliance standards are met.

RESPONSIBILITIES

• Monitor workflows and incoming treatment plan volume for a team of medical professionals to ensure regulatory deadlines and performance goals are met.
• Oversee Medical Management Compliance, evaluation of New Jersey specific regulations, training of staff, and evaluation of results to ensure the operation complies with all state requirements.
• Review and evaluate decisions made by Nurse Case Representatives and verify decisions made are within the standards of the Company’s Decision Point Review Plan and New Jersey AICRA requirements.
• Document case activities and action plans in a SOAP note format.
• Evaluate and identify workflow trends, quality assurance opportunities, and/or key issues, analyze available data and recommend corrective action.
• Provide overall support to the Medical Claims Department, effectively answer questions, handle customer / provider inquiry calls and assess claims decisions made.
• Assist in the development, review and implementation of policies and procedures to ensure consistency, quality and efficiency within the unit.
• Work closely with Medical Directors and the treating providers to assess, implement, and evaluate medical treatment provided to the injured person.
• Assist in the development, review and implementation of policies and procedures to ensure consistency, quality and efficiency within the unit.
• Review medical expense payments in accordance with Company claim guidelines for prompt payment processing.
• Work closely with the Nursing Supervisor to help manage and delegate the day-to-day operation of the unit.
• Assist the Nursing Supervisor with monthly/quarterly reports as needed.
• Review all Medical Management reports and analyze potential for change/improvement.
• Foster an environment that is team oriented, customer responsive, and quality driven.
• Handle project work at request of the PIP Directors and/or Supervisor.
• Act as a liaison for our IME (Independent Medical Exam) vendors.
• Other administrative tasks as needed

QUALIFICATIONS

• 5+ years of Medical Claim or Medical Administrative experience
• Functional knowledge of medical terminology and anatomy. Knowledge of ICD and CPT coding is preferred.
• Thorough understanding of the New Jersey AICRA regulations.
• Must have excellent written and verbal communication, analytics, and organizational skills.
• Strong critical thinking skills, the ability to exercise independent judgment and the ability to solve problems effectively.
• Demonstrated leadership skills with the ability to motivate, coach, and influence team performance and operational goals. Prior supervisory experience is a plus but not required.
• Proficient computer keyboard skills.
• Possess a strong working knowledge of Excel, including the development of charts and visual data for analytics.
• Ability to build reports, pivot tables, and utilize Tableau is a plus.
• An ability to multi-task and work independently

SALARY RANGE

The pay range for this position is $83,000 to $107,000 annually. Actual compensation will vary based on multiple factors, including employee knowledge and experience, role scope, business needs, geographical location, and internal equity.​

ABOUT THE COMPANY

The Plymouth Rock Company and its affiliated group of companies write and manage over $2 billion in personal and commercial auto and homeowner’s insurance throughout the Northeast and mid-Atlantic, where we have built an unparalleled reputation for service. We continuously invest in technology, our employees thrive in our empowering environment, and our customers are among the most loyal in the industry. The Plymouth Rock group of companies employs more than 1,900 people and is headquartered in Boston, Massachusetts. Plymouth Rock Assurance Corporation holds an A.M. Best rating of “A-/Excellent”.

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