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Team Lead, Out of Network Medical Claims


This is a Full-time position in Irving, TX posted August 30, 2021.

JOB SUMMARY: The Lead is responsible for assisting the supervisor with day-to-day workflow of the Department. In addition, this job is responsible for the handling, research, and communication regarding complex and escalated claims inquiries stemming from clients, providers, and team members.


1. Assist Supervisor in daily operations and processes within the department

2. Identify and notify the supervisor of potential escalated issues or system related concerns.

3. Assist in training new employees and remedial training for existing employees, including new or revised procedures

4. Provide general support to the team members, serve as a resource and answer questions Serves as subject matter expert and as back-up within the team.

5. Coach and mentor staff while assisting with more challenging issues and cases.

6. Support the quality audit review and rebuttal process

7. Ensure the maintenance of and compliance with department performance metrics for production, accuracy, and turnaround time

8. Foster and maintain relationships with internal and external customers, including but not limited to the provider, client, member or other internal customer

9. Monitor compliance with all departmental policies, procedures, and workflows and collaborate with the training team, as necessary.

10. Review workflows and outputs to recommend appropriate workflow revisions and collaborate with other internal departments.

11. Lead and/or participate in various research projects for Sr. Management and Clients, as assigned.

12. Collaborate, coordinate, and communicate across disciplines and departments.

13. Ensure compliance with HIPAA regulations and requirements.

14. Demonstrate Company’s Core Competencies and values held within.

15. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.

Please note due to the exposure of PHI sensitive data – this role is considered to be a High Risk Role.


The incumbent impacts efficiency and effectiveness of departmental operations. This is an entry level leadership role that has the authority and responsibility to facilitate and communicate training, new processes, coaching, and mentoring. The incumbent works independently under minimal supervision but collaborates and communicates with the supervisor or manager on a daily basis. Specific to HR actions such as hiring, salary adjustments, position changes, termination and other disciplinary actions, the incumbent refers to the Supervisor or Manager.

Job Requirements:
• Minimum completion of high school (i.e., diploma or GED)

• Minimum 2 years of experience in the healthcare industry or customer service. Leadership experience preferred

• Required licensures, professional certifications, and/or Board certifications as applicable

• Knowledge of claims processing and procedures

• Knowledge of applicable laws and statutes (state, local or federal) for positions focusing on Workers’ Compensation or automobile medical “auto” bills.

• Communication (written, verbal and listening), problem solving, organization, and time management skills

• Strong verbal and written communication skills

• Ability to multitask and handle multiple projects simultaneously, prioritize and meet expected deadlines

• Ability to lead and mentor others in a positive and respectful manner

• Ability to identify issues and determine appropriate course of action for resolution

• Ability to use software and hardware related to job responsibilities, including MS Office with preferred proficiency in MS Word and MS Excel spreadsheets and database software

• Ability to adjust workflow and alter schedule to meet deadlines in a fast-paced environment

• Ability to work independently and handle confidential information

• Individual in this position must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier and telephone

As an Equal Opportunity Employer, the Company will provide equal consideration to all employees and job candidates without regard to sex, age, race, marital status, sexual orientation, religion, national origin, citizenship status, physical or mental disability, political affiliation, service in the Armed Forces of the United States, or any other characteristic protected by federal, state, or local law.

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