Lead Analyst, Claims

Public Consulting Group LLC (PCG) is a leading public sector solutions implementation and operations improvement firm that partners with health, education, and human services agencies to improve lives. Founded in 1986, PCG employs approximately 2,000 professionals throughout the U.S—all committed to delivering solutions that change lives for the better. The firm is a member of a family of companies with experience in all 50 states, and clients in three Canadian provinces and Europe.

PCG offers clients a multidisciplinary approach to meet challenges, pursue opportunities, and serve constituents across the public sector. To learn more, visit  .

Our Education team offers consulting services and technology solutions to help schools, school districts, and state education agencies/ministries of education promote student success, improve programs and processes, and optimize financial resources. We work with clients to ensure all students have what they need to succeed.

Services:

• Teaching

• Learning Solutions

• Data Systems

• IT Solutions

• Financial Solutions

• Equity in Education

• Equitable Education

• Recovery Services

The TPA Claiming Lead will lead all efforts of the TPA Claiming Operations Team within the School-Based Services (SBS) Center of Excellence (COE) Operations functional area. This position will direct claims management for TPA models. This role will take ownership for fidelity, efficiency, and optimization in our TPA claiming work. This role must effectively integrate capabilities in claims management, data management, and project management to promote strong collaboration with the Client Success, Technology, and Program Integrity functional areas to execute contractual obligations.

The TPA Claiming Lead will also work with Regional Leadership to understand state and local environments, allowing them to effectively implement and expand the PCG claiming operations program.

The ideal candidate should be reflective and thoughtful about PCG’s processes and ready to build and support a team that will develop and implement a consistent, efficient claiming program with capacity for scalable growth and adaptation to meet evolving policies and client needs.

• Analyzes and reviews claims for accuracy, completeness and eligibility.

• Provides leadership, supervision and coaching to junior department staff.

• Prepares and submits claims data for multiple clients within multiple states.

• Analyzes the development of claims assigned at each level of the adjudication process.

• Provides support and give direction to less experienced staff

• Evaluate medical records and apply evidence to each case.

• Provides monthly reporting statistics.

• Ensures adherence to claim timeliness and accuracy performance standards.

• Prepares for and participate in various meetings, including status reports, process improvement meetings and meetings related to collection of required data.

• Conducts policy and other research.

• Assists with quality control projects, including case reviews to ensure the integrity of claim methodology and eligibility determinations.

• Assists with preparation of other written reports and materials for clients.

• Assists in administration of time studies and operation of help desk lines.

• Trains others on the function of analyzing claims.

• Understand Federal, State, and local Medicaid policies as they pertain to our Education clients and our systems for processing and submitting claims

• Seek continuous improvement throughout the service/claim adjudication journey

• Represent the TPA team as member of SBS COE leadership team, balancing FFS team needs with broader COE initiatives and efforts

• Act as an escalation point of contact for TPA Claiming Operations

• Manage budget and resource leveling for TPA Claiming Operations in support of building PCG’s reputation as a trusted partner

• Solicit feedback from members of the TPA Claiming Operations Team and champion initiatives that address the evolving needs of our clients

• Establish best practice models and structures for claims processing and adjudication, including coordinating involvement from other functional areas (e.g., creation of new technical functions)