Claims Analyst

Job Summary: 

The Claims Analyst will provide timely and accurate processing and adjudication of claims. The role will research, and process claims or related requests for covered members or providers across various products including medical, pharmacy, vision and related healthcare or ancillary benefits options 

Duties and Responsibilities:

• Work from a queue to review assigned claims or requests at a set inventory level.
• Examine claims to identify key elements and processing requirements based on diagnosis, provider, medical policy, contract and/or policy.
• Perform rework, med review, or other projects as assigned.
• Identify and report adjudication inaccuracies that are related to system configuration, benefit inconsistency, and fee schedules.
• Efficiently and accurately analyze medical claims to determine whether or not the claim should be approved or denied for payment in accord with the plan / client conditions.
• Resolve pended healthcare claims and prior approval requests.
• Assist other departments by working on projects and or providing feedback, research, and resolution to inquiries regarding claims adjudication.
• Achieve and exceed key performance indicators for performance, production, and quality.
• Develop in role, team and organization through active participation in knowledge transfer and support of engagement and initiatives.

Required Skills, Knowledge, and Abilities:

• High School Diploma or equivalent. Bachelor’s degree preferred or experience in lieu of degree.
• 6 months of experience in a health benefits role with medical terminology familiarity
• 2 years of medical claims processing including knowledge of medical terminology and working in a production environment preferred
• Ability in using a computer which includes expert keyboard and navigation skills and learning new programs.
• Communicate clearly and professionally with internal and external customers.
• Work effectively as part of a team to achieve established outcomes. Understand other’s roles and empower one another to take responsibility to be successful.  
• Demonstrate a collaborative interaction with peers to reach a common goal as well as be a resource to team members and internal/external customers.
• Pay close attention to detail in all aspects of the job.
• Make decisions using available resources and sound judgment. 
• Maintain confidentiality and discretion.
• Identify and resolve problems in a timely manner, gather and analyzes information skillfully.
• Share knowledge with associates by effectively communicating and providing follow-up.  
• Open to other’s ideas and exhibits a willingness to try new things.
• Demonstrate accuracy and thoroughness; monitor work to ensure quality.
• Prioritize and plan work activities to use time efficiently.
• Adapt to changes in the work environment, manage competing demands and is able to deal with frequent change, delays, or unexpected events.
• Follows instructions, responds to direction, and solicits feedback to improve.
• Act in such a way to instill trust from management, other associates, as well as customers.  
• Work overtime as required, including weekends.

Physical and Cognitive Demands: The physical demands described here are representative of those necessary for an employee to successfully perform the essential functions of this job. Reasonable accommodation can be made to enable individuals with disabilities to perform the essential functions.

• Constant: Talk, hear, speak, and use hands and fingers to operate a computer, telephone, keyboard/mouse; occasionally move about the office
• Constant: Specific vision abilities required by this job include close vision requirements due to computer work for full shift
• Occasional: Lift and/or move up to 10 pounds
• Occasional: Ability to uphold the stress of occasional travel between offices
• Constant: Regular, predictable attendance in the office is required
• Constant: While performing the duties of this job, the employee is regularly sitting for the full shift.
• Constant: The cognitive skills needed to complete tasks include abilities such as learning, remembering, focusing, categorizing, and integrating information for decision making, problem-solving, and comprehending. 

Work Environment: The work environment described is representative of what must be met by an employee successfully perform the essential functions of this job.  

• The physical environment is indoors in a controlled climate, office setting. The noise level may be low to moderate.

The duties described are representative, but not restrictive of tasks that may be assigned or of the abilities required to do the job. The description is subject to change at any time. Other related duties may be assigned. This description does not alter the at-will status of employment.