Hospital Claims Analyst

Under the general direction of the Director of Business Services, the Hospital Claims Analyst performs accurate and timely filing of initial and secondary insurance claims, follow-up on unpaid claims, and ensures payment to the hospital and affiliated entities to maintain adequate cash flow and accounts receivable balance. This role operates in accordance with TJC, federal, state, and local guidelines, organizational and departmental policies, and procedures. The position requires communication with medical staff, other departments, and outside agencies while maintaining confidentiality, self-motivation, creativity, and the ability to function semi-autonomously in a fast-paced, dynamic environment.

Responsibilities

• Processes and adjusts inpatient and outpatient medical claims in a timely fashion according to departmental quality and production standards.
• Assists the Director of Business Services in researching and determining the status of medical claims to ensure billed dollars, claims aging, and pend values align with contract provisions.
• Performs follow-up and takes necessary actions to resolve errors and findings assessed by Internal Audit and performance improvement plans.
• Ensures the validity of claims by reviewing files and attached documentation for completeness and accuracy.
• Identifies patterns in resubmitted and adjusted claims, errors, trends, and inconsistencies that require revisions to claim guidelines or system modifications.
• Documents systemic root cause analysis and recommends solutions to the Director of Business Services.
• Resolves claims issues by researching claim situations and providing timely reports and responses.
• Enhances department productivity by recommending improvements to workflow processes and organizational structure.
• Ensures the completeness and accuracy of Standard Operating Procedures by providing feedback to the department director.
• Contributes to team efforts by accomplishing related goals and results as determined by the Insurance and Billing Department leadership team.
• Maintains documentation to support avoidance of negative financial, regulatory, and operational impact.
• Researches and responds to inquiries from various departments.
• Provides detailed reporting on claims volume, billed charges, savings, and other metrics.
• Increases subrogation recovery efforts on approved claims.
• Assists in gathering customer feedback, defining processes, and identifying best practices.
• Handles Protected Health Information (PHI) and maintains member privacy in accordance with HIPAA standards.
• Exhibits proficiency in all realms of insurance billing, including managed care and commercial.
• Demonstrates thorough knowledge of hospital billing formats, specifically UB-04s, 1500s, and contract billing.
• Reviews every account on ATB for insurance financial class and resolves auto-rejected claims (except Medicaid and Medicare, which are forwarded to the appropriate analyst).
• Forwards secondary A/Rs to the Business Services Secondary Insurance Primary A/R Analyst.
• Adds insurance information into the system and sets accounts to bill.
• Reviews all credit balance accounts and processes patient refunds.
• Reviews accounts on ATB for correct contractual and non-covered services.
• Identifies master accounts and test accounts on ATB.
• Reviews accounts on PP/ATB regarding denials due to lack of patient response.
• Identifies and writes up adjustments such as employee discounts, professional courtesy discounts, and forwards accounts for bad debt processing.
• Assists in answering phone calls and walk-ins.
• Participates in continuing education and training to maintain and improve professional skills and knowledge of the patient population served.
• Ensures compliance with infection control, OSHA, and safety standards.
• Performs other duties as requested, required, or assigned within the scope of the job and training.

Requirements

• Minimum education level equivalent to a high school diploma.
• Formal training in claims experience skills, including investigation, resolution, and operations.
• Skills and experience in planning, organizing, implementing, facilitating, and verbal/written communications.
• Basic typing skills, ability to manage cash and make change, and proper telephone etiquette.
• Preferred: Formal classes in Medical Office Procedure and Medical Billing.
• Two years of billing/collection experience in the healthcare field.
• Intermediate computer skills, including Microsoft Office Suite (Word, PowerPoint, and Excel), and experience with scheduling appointments/updating calendars.

Schedule

Monday through Friday, 8:30 AM – 5:00 PM.