Claims Processing Analyst I

General Purpose of Job

The Claims Processing Analyst performs claims analysis and associated responsibilities in support of claims administration, and performs other related work as required.

Essential Duties and Responsibilities

• Validate submitted claims data to ensure accuracy, validity and integrity.
• Analyze pending claims, collaborating with internal business partners for necessary information and assistance, according to departmental procedures.
• Effectively prioritize and complete all assigned tasks within appropriate timeframes and with required level of quality.
• Evaluate claims issues and procedures to identify and suggest opportunities for improvement, both in efficiency and quality.
• Openly participate in team meetings, providing ideas and suggestions to ensure departmental best practices, and to develop and promote teamwork.
• Maintain required compliance with privacy and confidentiality standards.
• Maintain or exceed all established standards for performance, quality and timeliness.
• Support the Claims department in review, investigation, and research of claims issues and completion of claims projects.
• Communicate effectively, in verbal or written form, by sharing ideas and reporting facts and issues.
• Demonstrate business practices and personal actions that are ethical and adhere to all Health System and Health Plan policies and procedures.
• Absorb other related work responsibilities as requested.

Education and/or Experience

• High school graduate or GED required.
• Minimum of two years professional experience in claims analysis, provider medical billing, or medical coding.
• Experience with Microsoft Excel and Word, as well as with medical terminology, coding and billing concepts.
• Experience with health insurance and managed care principles.
• Ability to work independently, or in a team environment, toward meeting common goals.
• Integrity and discretion to maintain confidentiality of member and provider data.
• Ability to apply mid-level concepts of claims adjudication, following established procedures and workflows for completion of assigned tasks.
• Ability to multi-task and meet deadlines in a fast-paced environment.