Claims Analyst Team A

Position Summary:


The Claims Analyst accurately processes medical, dental, orthodontia and pharmacy claims for timely payment to providers and members. Must be able to interpret and apply a wide variety of provider reimbursement methodologies, benefit plan designs, employer/member contracts and Medicare pricing methodologies.

Qualifications:


EDUCATIONAL REQUIREMENTS
None Specified

CERTIFICATION & LICENSURE REQUIREMENTS
None Specified

EXPERIENCE REQUIREMENTS
One (1) year medical claims adjudication, healthcare billing or healthcare customer service experience.

SKILLS AND KNOWLEDGE
Ability to organize, prioritize and remain flexible is essential in order to meet turnaround times and performance guarantees. Knowledge of medical, dental and pharmacy benefits; medical and dental terminology; provider contracting, Medicare reimbursement methodologies, Explanation of Benefits, familiar with healthcare coding requirements (ICD-9, ICD-10, CPT, CDT, HCPCS) and legislation, and claim billing forms (CMS1500, UB04, dental claim form, as well as electronic billing formats).

Essential Functions:

• Adjudicates claims at a high level of productivity and accuracy as measured by individual weekly performance audits.
• Prioritizes, manages and balances workload daily utilizing pended claim reports, paper claim sorting and balancing to ensure performance guarantees are met and payment of interest is avoided.
• Corresponds as required by legislation and claim policies with providers and members by letter and phone on occasion to notify member and provider of claim denials or missing information.
• Researches and analyzes miscellaneous document submissions to effectively determine course of action and impact to pended or finalized claims.