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JOB PURPOSE:

The Claim Analyst will play a pivotal role in enhancing the efficiency and effectiveness of the claims department by evaluating and refining processes, conducting comprehensive data analysis, and ensuring compliance with all applicable State, CMS, and contractual guidelines. This position requires a working knowledge of Government Programs medical claims payment system and configuration with strong focus on data review and analysis to drive process improvements and achieve measurable outcomes.

JOB RESPONSIBILITIES:

+ Evaluate and propose revisions to existing SLAs with claims TPA, or introduce new SLAs to streamline processes and enhance operational efficiency. Track and monitor TPA’s open tickets. Collaborate with TPA to ensure timely update to claims system configuration to reflect payment integrity.

+ Ensure accurate logging and processing of refund checks in the database, facilitating expedited credit of returned monies and proper application of transaction by our TPA.

+ Perform in-depth claims analysis using multiple data sets, conduct root cause analysis, and drive process improvements to achieve measurable outcomes and operational efficiency.

+ Support stakeholders in claims appeals: review and track claims appeals and grievances, prepare reports, and provide status updates to ensure timely and accurate resolution.

+ Prepare analysis on network provider performance through the development of monthly provider scorecard, working with other key stakeholders to ensure providers are meeting their contractual requirement and identify areas for improvement.

+ Maintain a high level of customer service for both internal and external customers, addressing inquiries and resolving issues promptly.

+ Collect and prepare data for state, federal, and internal inquiries, ensuring accuracy and compliance with regulatory requirements.

+ Investigate suspense conditions to determine if system or procedural changes could enhance claim workflow and efficiency.

+ Analyze patient and medical information to identify Coordination of Benefits (COB), Worker's Compensation, No-Fault, and Subrogation conditions.

+ Validate Diagnosis-Related Group (DRG) grouping and (re)pricing outcomes presented by the claims processing vendor to ensure accuracy.

+ Attend Joint Operating Committee (JOC) meetings with providers to communicate proper billing procedures and explain company coverage guidelines.

+ Coordinate with Finance Department regarding check runs and provider payments, including handling refunds, overpayments, and underpayments.

+ Review and investigate claims to be adjudicated by the Third-Party Administrator (TPA), applying contractual provisions in accordance with provider contracts and authorizations.

+ Compile and analyze claim reports for adjustments resulting from external providers, vendors, and internal inquiries in a timely manner.

+ Assist management with timely and accurate response to internal and external audit inquiries, including government agencies.

+ Other duties as assigned.

Schedule: 8:30AM – 5:30PM

Weekly Hours: 40

QUALIFICATIONS:

Education: Bachelor's degree required. Certified Professional Coder a plus.

Experience:

+ 3-5 years of healthcare experience, managed care setting is strongly preferred.

+ Proficiency in data analytics, i.e. SAS, SQL.

+ Claims adjudication and understanding of claims PPS is strongly preferred.

+ Knowledge of Medicaid and Medicare benefits, enrollment and billing, and provider contracting is strongly preferred.

+ Knowledge of CPTs, ICD 9/ICD 10, HCPC, DRG, Revenue, RBRVS

+ Proficiency in MS Excel, Word, PowerPoint, and experience using a claims processing system or comparable database software.

+ Effective oral, written, and interpersonal communication skills are required.

+ Able to multitask efficiently, effectively, and timely.

+ Strong organizational skills and work ethic.

+ Detail-oriented, professional and collaborative, a great team player.

Physical Requirements

Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to:

+ Standing – Duration of up to 6 hours a day.

+ Sitting/Stationary Positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.

+ Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA guidelines, etc.

+ Bending/Squatting – Have to be able to safely bend or squat to perform the essential functions under the scope of the job.

+ Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas.

+ Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools to complete essential job functions (ie. typing, use of supplies, equipment, etc.)

+ Sight/Visual Requirements – Must be able to visually read documentation, papers, orders, signs, etc., and type/write documentation, etc. with accuracy.

+ Audio Hearing and Motor Skills (Language) Requirements – Must be able to listen attentively and document information from patients, community members, co-workers, clients, providers, etc., and intake information through audio processing with accuracy. In addition, they must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.

+ Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.

Disclaimer: Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company.

We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities.

Salary Range (Min-Max):$70,000.00 - $80,000.00