Medical Claims Data Processing Review Team Lead

Job description

Medical Claims Data Processing Review Team Lead The Opportunity: Develops, evaluates, documents, applies and implements policies, procedures or regulations to meet organizational, industry, and governmental requirements. Applies leading-edge principles, theories, and concepts; contributes to the development of new principles and concepts. Works on unusually complex problems and provides highly innovative solutions. Operates with substantial latitude for unreviewed action or decision; mentors or supervises employees in both company and technical competencies. You Have: Experience leading and mentoring Medicaid and CHIP Data Processing (DP) review teams, ensuring correct interpretation of federal and state requirements and consistent, PERM compliant review execution Experience managing large-scale review operations, including planning and overseeing workloads of up to 16,150 FFS and managed care claims across onsite and remote environments Knowledge of MMIS, state payment systems, vendor systems, provider enrollment systems, RBS compliance requirements, and multi-system claim verification, including PBM, dental, waiver, imaging, and financial systems Knowledge of complex Medicaid and CHIP payment methodologies, including DRG, per-diem, capitation, PCCM, disease management, wrap payments, waiver payments, NEMT, HIPP, stop loss, and aggregate payment structures Knowledge of PERM documentation standards, including screen print completeness, SMERF packet assembly, qualifier and sub-qualifier requirements, cross-referencing, and defensible audit traceability Ability to provide SME-level guidance on complex DP determinations involving multi-system discrepancies, rate logic issues, capitation assignment, TPL workflows, RBS verification, and system anomalies Ability to ensure reviewers identify, document, and categorize all DP errors, including multiple errors per claim, using tools such as SMERF, review modules, and rate references Ability to implement and oversee QA and QC procedures, resolve escalations across Tier levels, and deliver corrective training for reviewer knowledge gaps HS diploma or GED Nice If You Have: Bachelor's degree Compensation At Booz Allen, we celebrate your contributions, provide you with opportunities and choices, and support your total well-being. Our offerings include health, life, disability, financial, and retirement benefits, as well as paid leave, professional development, tuition assistance, work-life programs, and dependent care. Our recognition awards program acknowledges employees for exceptional performance and superior demonstration of our values. Full-time and part-time employees working at least 20 hours a week on a regular basis are eligible to participate in Booz Allen’s benefit programs. Individuals that do not meet the threshold are only eligible for select offerings, not inclusive of health benefits. We encourage you to learn more about our total benefits by visiting the Resource page on our Careers site and reviewing Our Employee Benefits page. Salary at Booz Allen is determined by various factors, including but not limited to location, the individual’s particular combination of education, knowledge, skills, competencies, and experience, as well as contract-specific affordability and organizational requirements. The projected compensation range for this position is $99,000.00 to $225,000.00 (annualized USD). The estimate displayed represents the typical salary range for this position and is just one component of Booz Allen’s total compensation package for employees. This posting will close within 90 days from the Posting Date. Identity Statement As part of the hiring process, we will ask you to complete an identity verification process that leverages advanced biometrics and artificial intelligence to ensure authenticity and protect against identity fraud. You are expected to be on camera during interviews and assessments. We reserve the right to take your picture to verify your identity and prevent fraud. Candidate AI Usage Policy AI is a part of our daily work at Booz Allen, and we are committed to the responsible and ethical use of AI tools. However, we want to ensure a fair candidate process based on your own skills and knowledge. As part of this commitment, the use of artificial intelligence (AI) or other tools to assist with responses during interviews (whether in-person or virtual) is prohibited unless permission is explicitly provided . Work Model Our people-first culture prioritizes the benefits of collaboration, whether it occurs in person or virtually. To support engagement and effective communication, employees working virtually are generally expected to have their cameras on during meetings. Remote : If this position is listed as remote, there may still be occasions when you are required to work in person at a Booz Allen or customer facility. Hybrid : If this position is listed as hybrid, you will be expected to work from a Booz Allen facility frequently, in alignment with leadership expectations and the needs of the role. You may also be required to work from or visit a customer facility. Onsite : If this position is listed as onsite, work will primarily be performed at a Booz Allen office or customer facility, where employees will collaborate directly with colleagues and customers as required by the role. Commitment to Non-Discrimination All qualified applicants will receive consideration for employment without regard to disability, status as a protected veteran or any other status protected by applicable federal, state, local, or international law.