Job Description
Job Description
Role: Claims Analyst
Organization: Edenbridge PACE at Skyland
Location: Washington, DC SE
Status: Full-time
Mission: To allow frail elderly people to age in the location of their choosing and continue to lead connected, meaningful lives
JOB SUMMARY
The Claims Analyst reviews, processes and analyzes healthcare claims to determine their validity and accuracy. They assess damages, verify policy coverage and ensure compliance with regulations and company procedures. Effective communication, problem-solving and attention to detail are crucial for this role.
ESSENTIAL DUTIES AND RESPONSIBILITIES
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Reviews submitted claims for accuracy, completeness and adherence to policy terms and legal requirements.
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Analyzes claim data to identify trends, patterns, and potential irregularities.
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Communicates with stakeholders to gather information, explain decisions, and resolve issues.
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Investigates potential fraudulent claims and gathering supporting evidence.
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Makes informed decisions on claim validity and determining appropriate compensation.
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Maintains accurate and detailed records of claims processing and outcomes.
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Ensures adherence to relevant regulations and company policies.
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Develop and maintain positive relationships with the network of providers through ongoing
communication and by providing feedback
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Performs other duties as required.
QUALIFICATIONS
Education and Experience:
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High School Diploma. Associate’s Degree preferred.
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1-3 years of experience in data analysis in a customer service environment within the healthcare insurance industry preferred.
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Experience analyzing data, identifying discrepancies and making informed decisions.
Skills and Competencies:
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Able to clearly explain complex information, both verbally and in writing.
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Able to identify and resolve issues related to claims processing.
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Strong attention to detail to ensure accuracy in claim review and data entry.
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Knowledge of Insurance/Healthcare, including understanding policy terms, coverage, and relevant regulations.
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Exceptional customer service skills.
Learn more at:
edenbridgepace.com/dc