Claims Analyst II

Claims Processor

Analyzes claims and/or adjustments submitted in Centers for Medicare and Medicaid Services Form 1500 (CMS-1500) and Uniform Billing Form 04 (UB-04) formats, as well as member reimbursements, by applying payment rules to determine appropriate adjudication, denial, or the need for additional information. This includes the review of original claims, adjustments, Coordination of Benefits (COB), and grievances from Puerto Rico providers, non-participating providers, and providers in the United States, as well as reimbursement requests originating from countries outside the United States and Puerto Rico, up to the maximum adjudication authority limit established by current policies and procedures.

Evaluates, applies, and uses payment rules and policies in adjudicating claims and/or adjustments of claimed services in other standardized formats in the health industry.

Processes all types of original claims, adjustments, grievances, and reimbursements to members.

Communicates any evidence of possible utilization or attempted fraud that may be detected during the claim adjudication process.

Refers claims and/or adjustments to areas and/or departments necessary to obtain additional information, the outreach process, and/or approvals for payment adjudication awards and/or denial.

Reports to their immediate supervisor any evidence of possible deficiency in the system configuration of the policyholder's coverage of the contract with the provider that may be detected during the claim adjudication process.

Notifies the immediate supervisor of any evidence of payment error or decline that may be detected during the claim adjudication process.

Executes the average of claims established by the company (which may vary from time to time), maintaining financial accuracy and processing claims and/or adjustments applicable as established in the current policy and procedure.

Complies with the delivery of the productivity report.

Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our industry, to maintain appropriate business and employment practices.

May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

Education and Experience: Bachelor's Degree. At least one (1) year of experience in claims processing and adjudication, applying payment policies, fee schedules, and coding guidelines, or in a Provider Call Center in the Health Insurance Industry.

OR Education and Experience: Associate's Degree or at least sixty to sixty-four (60-64) approved college credits. At least two (2) years of experience in claims processing and adjudication, applying payment policies, fee schedules, and coding guidelines, or in a Provider Call Center in the Health Insurance Industry.

OR Education and Experience: High School Diploma or Technical Course. At least three (3) years of experience in claims processing and adjudication, applying payment policies, fee schedules, and coding guidelines, or in a Provider Call Center in the Health Insurance Industry.

"Proven experience may be replaced by previously established requirements."

Certifications/Licenses: N/A

Other: Knowledge of payment rules, medical terminology, and standardized healthcare coding systems. Proficiency in managing and interpreting the Current Procedural Terminology, Fourth Edition (CPT-4), International Classification of Diseases, Tenth Revision (ICD-10), and Healthcare Common Procedure Coding System (HCPCS) coding manuals to ensure accurate claim adjudication and processing.

Languages: Spanish Intermediate (comprehensive, writing, and verbal)

English Intermediate (comprehensive, writing, and verbal)