Returning Candidate?

Lead Associate- Claims

Lead Associate- Claims

Job ID 
Job Locations 
Claims Support Team

More information about this job


Reviews and investigates claims, enters claims into the CareCentrix computer system, matches claim data with the appropriate authorizations and determines correct claims payment, denial or adjustment. Analyzes resolves or refers questionable claims and authorizations or system issues as appropriate. Completes special assignments and analyzes provider requests. Guides team towards the successful collection of invoice processing activities to ensure receivables are reimbursed on an accurate and timely bases. During elevated collector activates, works directly with the payer’s point of contact, internal and external customers and other contract clients toward effective and efficient collection results. Mentors Claim Adjudicators and Claims Analysts and provides additional management support including inventory control and system testing. Works under general supervision.



  • Reviews plan, eligibility, patient notes, and authorizations to determine appropriate adjudication. Creates authorizations when necessary based on individual provider and carrier contracts.  
  • Reviews electronic claims or processes data as necessary into the claims system, resolves computer generated edit conditions, and determines appropriate payment or denial amounts. Documents notes as necessary.  
  • Identifies, analyzes and resolves or refers questionable claims, intakes, authorizations and system issues to appropriate Regional Care Center, Provider Relations, Data Management or Information Systems Management. Processes responses accordingly.
  • Researches and, if necessary, processes claim payment adjustments resulting from customer service referrals, audits or data inaccuracies as detected.  
  • Exercises good judgment, interprets medical claim data and contracts, and remains knowledgeable in related company policies and procedures.  
  • Achieves teamwork, production and quality standards in order to assure timely, efficient and accurate claim processing and timely reimbursement of receivables.  
  • Analyzes and responds to provider requests or issues and completes special assignments (e.g., investigate claim payment requests, rework change of benefit requests, audit patient and provider accounts.  
  • Assists other teams in a cross-functional manner as business needs dictate to maintain overall office standards.  
  • Interfaces with other departments or business centers as well as external providers.  
  • Supports management by managing claims inventory and controls as well as creating and maintaining related spreadsheets and reports.  
  • Performs claim processing demonstrations, assists with system testing, and elevates system issues as necessary.  
  • Facilitates training and coaching and mentoring when needed.  
  • Identifies/Resolves the possible root cause of inappropriate denials with payers. Analyzes and clears payment variances. May prepare adjusted and corrected bills and adjust accounts receivable entries in accordance with existing operation procedures.  
  • Maintains patient confidentiality and claims integrity in accordance with company policies and procedures.  
  • Demonstrates capability with Excel: Basic Pivot table ability, and ability to filter, create formulas, utilize v-lookup to combine two sets of data using a unique key.  
  • Effective written and verbal communication utilizing proper grammar and punctuation.  
  • Demonstrated critical thinker and financial acumen.  
  • Reviews and adheres to all Company policies and procedures and the Employee Handbook.
  • Participates in special projects and performs other duties as assigned.




To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.



  • Abides by and demonstrates the company Mission – Vision – Values through both behavior and job performance on a day-to-day basis.
  • Convey a strong professional image, exhibit interest and positive attitude toward all assigned work.
  • Adheres to and participates in Company’s mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.



  • Must be able to remain in a stationary position 90% of the time.
  • Occasionally move about the office to access file cabinets, office machinery, etc.
  • Constantly operates a computer and other office productivity machinery (i.e., a calculator, copy machine, and computer printer).
  • Frequently communicates via phone and email. Must be able to exchange accurate information in these situations.
  • Occasionally lift items weighing up to 10 pounds.


High School Diploma plus four years of claims processing, accounts payable, general accounting or equivalent experience required. At least two years of experience directly related to medical claims processing along with evidence of superior performance required. Broad knowledge of insurance and/or accounting procedures and PC software/hardware is necessary. Excellent analytical and communication skills also required. Knowledge of Utilization Management and URAC standards.


CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.