Claims Analyst

Claims Analyst II :

Job Description Summary

Process assigned medical claims pended for manual adjudication in assigned workflow roles. Accurately interpret benefit and policy provisions applicable to line of business. Review claim to determine coverage based on contract, provider status, and claims processing guidelines.

Essential Responsibilities :

• Review and accurately process assigned medical claims that pend for manual adjudication in claims processing workflow roles according to member’s plan benefits and department claims processing policies and procedures.
• Verify accuracy of data entry including patient information, procedure and diagnosis codes, amount(s) billed, and provider data.
• Review plan benefits and determine coverage based on contract and claims processing guidelines.
• Use Notes system to record pertinent information involving a claim or member.
• Review claims set-aside for further action and ensure they are released in a timely manner.
• Document issues that affect claims processing quality and advise team leader of claims processing concerns and / or problems.
• Provide feedback on standard operating procedures for continual process improvement.
• Provide assistance to other internal departments in responding to questions regarding claims processing.
• Provide back-up for Claims Analyst I role.

Supporting Responsibilities :

Work Experience :

One year work experience in a general office role required, or a combination of equitable work and education experience required. Health related experience preferred.

Education, Certificates, Licenses :

High school diploma or equivalent required.

Knowledge :

Ability to develop thorough understanding of products, plan designs, provider / network relationships and health insurance terminology. Research skills and ability to evaluate claims in order to enter and process accurately. Preferred computer skills include keyboarding and 10-key proficiency, basic Microsoft Word and Excel. Ability to prioritize work and perform under time constraints with minimal direct supervision. Ability to utilize Lean principles and provide claims mentorship to other team members. Team player willing to collaborate and help others accomplish team objectives. A fundamental understanding of self-insured business is helpful.