Job Description
Job Description
Summary/Objective
The Claims Analyst position works under general supervision while conducting administrative activities for the Claims Department. These activities involve supporting Claims Management and Claims staff with claims related to administrative matters.
Essential Functions
- Investigate potential fraud providers to determine if they need to be flagged in Claim processing system.
- Run biweekly check run process.
- Run and complete Management Inventory and Aging Report every Monday morning
- Delete claims from Claim processing system and document repository as requested
- Handle continuation of care letters processing and file updates
- Back up annual 1099-M process
- Back-up Claim’s Clerk
- Support Programming Analyst by running and scrubbing basic reports.
- Identify system processing trends to share with Programming analyst for comprehensive analysis
- Run standard pre-designed departmental reports upon request
- Prepare and maintain daily/weekly production reports
- Compile and prepare audit review data for management review
- Manage members auto adjudication status
- Cobine SFTP files as needed
- Assist with reviewing and keying table updates
- Reconcile weekly check run dollars and numbers
- Prepare monthly claim invoices for review
- Reconciliating Third Party out of network claim reports
- Key daily production numbers into dashboard, aging reports, and any other production reports as needed.
- Assist with implementation projects
- Maintain department issue log and projects
- Coordinate with Programming Analyst, Vendors, and Operations on system enhancements
- Manage system tickets to ensure all deliverables are obtained and deadlines are met
- Prepare payment files
- Complete subpoena requests
- Other duties as assigned.
Competencies
- Must be able to maintain a high level of confidentiality.
- Must be flexible and have great organizational skills.
- Ability to multi-task, prioritize and work efficiently.
- Ability to build rapport and meaningful relationships with other departments.
- Ability to work independently, self-starter, energetic.
- Ability to demonstrate good common sense and sound judgment.
- Ability to communicate clearly and professionally, both verbally and in writing.
Education
- High School diploma or equivalent.
Specialized skills/technical knowledge
- Data mining, data analytics, data scrubbing
- Knowledge of medical terminology and claims is desired but not required.
- Must be able to handle a high quality and productive environment.
- Appropriate office phone etiquette and ability to communicate professionally with external parties including attorneys and Plan participants.
- Knowledge of healthcare coding systems and methodologies such as CPT, ICD-10 and DRG.
- Must have excellent communication (written, verbal, listening) organizational, and problem-solving skills.
- Proficient in Microsoft Office applications, primarily Word and Excel. Strong in Excel