Claims analyst

Claims Analyst

Job Title: Claims analyst

Location: Omaha NE 68154

Duration: 12 months

Job Description:

Family Summary/Mission

Achieve superior claim and member service performance through an integrated process of operational, quality, medical cost, and resource management meeting and/or exceeding member, plan sponsor, and provider expectations.

Position Summary/Mission

Reviews and adjudicates routine claims in accordance with claim processing guidelines.

Fundamental Components & Physical Requirements include but are not limited to

(* denotes essential functions)

Analyzes and approves routine claims that cannot be auto adjudicated. (*)

Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process. (*)

Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues.

Routes and triages complex claims to Senior Claim Benefits Specialist. (*)

Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements. (*)

May facilitate training when considered topic subject matter expert. (*)

In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic Correspondence Handling System-system used to process correspondence that is scanned in the system by a vendor). (*)

Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., utilizes Claim Check, reasonable and customary data, and other post-containment tools). (*)

Performance Measures

Background/Experience Desired

Experience in a production environment.

Claim processing experience.

Qualifications

Education and Certification Requirements

High School or GED equivalent.

Additional Information (situational competencies, skills, work location requirements, etc.)

Ability to maintain accuracy and production standards.

Analytical skills.

Technical skills.

Oral and written communication skills.

Understanding of medical terminology.

Attention to detail and accuracy.

All your information will be kept confidential according to EEO guidelines.