Claims Analyst

Job Summary

The Claims Analyst will work with the Senior Director of Medicare Operations to identify potential areas for process improvement initiatives, supporting the development of automation, payment accuracy, audit activities, business rules, and P&Ps. Responsibilities include claims systems utilization, capacity analyses, reporting, claims-related business and systems analysis, configuration support, evaluation and analysis of business needs, document creation, report preparation, and project management.

Functions & Job Responsibilities

• Claims systems utilization, capacity analyses/planning and reporting
• Analyze requirements for any Claim related projects
• Provide configuration support based on business needs including but not limited to DOFR, Benefits, and MOOP
• Evaluate and Analyze any business needs including but not limited to DOFR, Benefits, and MOOP related to Claims Department
• Review and recommend improvement to current configuration
• Document and Report to Senior Claims analyst and Director of Medicare Operations
• Perform Test Cases, Run Test, study and analyze result, and troubleshoot if necessary
• Absolutely validate accuracy of reports produced and submitted by the Claims Department
• Assists in preparing and reviewing cases for regulatory and other health plan reports and requirements
• Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
• Create Business Requirement Document as needed
• Create CMS Reports as needed by Director of Operations
• Manage and support new projects and regulatory updates in accordance with CMS

Qualifications

• Education/Experience: High School diploma or equivalent required. Associate degree or an equivalent combination of education and claims processing experience preferred. Bachelor’s degree in related field (preferred). 2 to 5 years of experience in a managed care claims processing environment required.
• Demonstrate knowledge of applicable claims processes (e.g., end-to-end claims cycle, auto-adjudication, manual work processes, payment methodologies, rework/adjustment processes)
• Terminology, CPT, revenue codes, ICD10, HCPCS codes as it relates to claims processing adjudication
• Core claims processing systems and healthcare authorization systems

Skills

• Perform in a fast-paced environment and work under pressure
• Communicate clearly and concisely, both verbally and in writing to individuals of diverse backgrounds
• Organize, plan and prioritize work activities, possess analytical and problem-solving skills
• Troubleshoot claims adjudication problem areas
• Encourage and utilize suggestions and new ideas
• Comprehend and interpret provider contracts and Divisional Financial of Responsibility (DOFR)
• Utilize and access computer and appropriate software (e.g., Microsoft: Word, Excel, PowerPoint) and job-specific applications/systems (e.g., EZCAP Claims Processing System and Authorization system)

Wage Range

$88,000.00 to $100,000.00 per year

Physical & Working Environment

• Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation: Must be able to travel when needed or required
• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.
• Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly
• Work is performed in an office environment and/or remotely
• The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business