Description

JOB SUMMARY

The Claims Analyst is responsible for claims processing, research and adjudication to correctly apply benefit determination and pricing for areas of responsibility to include clinic professional claims, hospital and facility inpatient and outpatient claims, and Rx-drug claims (CMS 1500 and UB04), in accordance with claims processing guidelines.

ESSENTIAL FUNCTIONS OF THE ROLE

Processes and adjusts professional and facility claims including, but not limited to, transplant, special handle, negotiations, and MSO according to claims processing guidelines. Maintains confidentiality rules in compliance with HIPPA guidelines.

Pends claims as directed by departmental policies and procedures; follows up for resolution and processes pended claims immediately following a benefit / payment determination.

Researches claims and adjustments; effectively gathers documentation needed to process claims and adjustments. Examines information including, but not limited to, authorizations, benefits, payments and denials.

Works claims inventory from assigned queues to ensure all claims are processed within established turnaround time as directed by department policies and procedures. Consistently meets /exceeds productivity standards and accuracy standards for payment, procedural and financial.

Performs follow-up and takes necessary actions required to resolve errors and findings assessed by the Quality Review Team.

Identifies and reviews systematic or procedural problems with Supervisor for timely follow-up and correction.

Completes reports / special projects to ensure prompt payment of claims.

KEY SUCCESS FACTORS

Medical terminology, CPT, HCPCS, ICD9, ICD10, and coding knowledge preferred.

Ability to use good judgment and logic in evaluating and resolving difficult claims issues.

Demonstrates full understanding of all products.

Ability to work independently, with minimal supervision to meet internal and external customer satisfaction goals. Must be a sound decision maker.

Responds positively to goal-setting and performance measurements. Easily adapts and responds effectively to shifts in priorities and unexpected events.

Excellent verbal and written communication skills, with attention to detail.

Ability to comprehend and adhere to policies and procedures.

Excellent analytical, problem solving skills and organizational skills.

May be required to work in excess of regular scheduled hours.

BENEFITS

Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level

QUALIFICATIONS

- EDUCATION - H.S. Diploma/GED Equivalent

- EXPERIENCE - 2 Years of Experience