Lead Claims Services Coordinator

Company Overview

Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.

Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem‑solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes – making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

Acentra Health is looking for a Lead Claims Services Coordinator to join our growing team.

Job Summary:

This position is responsible for supporting the claims adjudication process by adhering to internal policies and procedures and utilizing working knowledge of the client’s services to meet productivity and quality standards. The Lead Claims Services Coordinator will work with the claims and customer services teams to ensure claims are adjudicated accurately and in a timely manner.

• Assists the Operational Manager with escalations regarding claim processing inquiries, reporting, and issues.
• Prepares claim operational reports, such as the daily report of expiring claims, and provides to the claims processing team along with Leadership.
• Identifies any claim instance in which timeliness of SLA measure is of concern and immediately reports to the Operational Manager for further discussion and review.
• Coordinate with appropriate staff to ensure claims corrections requests, medical records, and reports are received and retained.
• Report and track all quality and fraud concerns (i.e. Incorrect billing) to the Operational Manager.
• Serve as team coach/ mentor to processors on the Claims team.
• Assists Operational Manager in tracking of production statistics, SLA compliance, and escalations.
• Develops and maintains working knowledge of internal policies, procedures, and services (both departmental and operational).
• Utilizes automated systems to log and retrieve information. Performs accurate and timely data entry of electronic faxes.
• Receives inquiries from customer service and communicates response within required turnaround times.
• Responds to inquiries in a prompt, accurate, and courteous manner following standard operating procedures.
• Performs verification of healthcare services to facilitate payment for received services.
• Assists in identification of medical claims meeting CPT/DRG audit criteria and submission of the necessary billing data and healthcare records to the third‑party auditor.
• Investigates and resolves or reports provider problems. Identifies and escalates difficult situations to the appropriate party.
• Meets or exceeds standards for claims adjudication and service level per department guidelines.
• Initiates cases by collecting and entering demographic, provider, and procedure information into the system.
• Responsible for the completion of daily, monthly, and quarterly reports necessary for client reporting.
• Serve as the most skilled or knowledgeable team member.
• Lead projects or teams, ensuring goals and deadlines are met.
• Triage and support team members, especially during shift work.
• Provide guidance and technical expertise to resolve complex issues.
• Assist in training and onboarding new team members.
• Lead by example and maintain high standards of performance.
• May assign daily tasks to team members and ensure efficient task completion.
• Act as the primary point of contact for project or team‑related issues.
• Do not approve timecards or handle day‑to‑day management of employees.
• Do not manage budgets, conduct performance reviews, or hire/fire employees.
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

The list of responsibilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.