Claims Review Analyst

Summary of Position

• Support contract performance management of a large health system.
  
  
• Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on contractual and industry guidelines.
  
  
• Identify and analyze single issues and trends to determine root causes.
  
  
• Provide recommendations for solutions to minimize errors and delays in systems and/or processes.
  
  
• Monitor system output to ensure proper functioning.

Roles & Responsibilities

• Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims review.
  
  
• Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is returned to the provider timely.
  
  
• Track issues and monitor trends to support their resolution.
  
  
• Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management.
  
  
• Improve quality, enhance workflow, and provide efficiencies within departments, identify opportunities for improvements; develop and present recommendations for changes.
  
  
• Conduct regular meetings with the assigned provider groups for status of AR files and recycles
  
  
• Support departmental goals for cycle time by organizing and tracking claims for review.
  
  
• Monitor and provide timely responses for the designated provider group emails and AR files.
  
  
• Perform other related tasks as directed or required.
  
  

Qualifications

Education, Training, Licenses, Certifications

• Bachelor's Degree.

Relevant Work Experience, Knowledge, Skills, and Abilities

• 2 - 3 years' prior related work experience in professional/facility claims or benefits/billing environment.
  
  
• Additional experience/specialized training may be considered in lieu of educational requirements.
  
  
• Strong knowledge of claim processing policies and procedures.
  
  
• Knowledge of medical terminology, ICD/CPT coding, per diem and DRG reimbursement and EDP testing procedures.
  
  
• Proficiency with MS Office applications (word processing, database/spreadsheet, presentation).
  
  
• Ability to accurately interpret information from contractual and technical perspectives.
  
  
• Must be conscientious and detail oriented; ability to recognize unusual patterns and troubleshoot for operational improvement and efficiencies.
  
  
• Strong analytical and problem-solving skills.
  
  
• Ability to effectively work on multiple projects/tasks with competing priority levels and deadlines.
  
  
• Ability to effectively absorb and communicate information.
  
  
• Strong Interpersonal and teamwork skills.

Additional Information

• Requisition ID: 1000002984
• Hiring Range: $48,600-$83,160

Required

Preferred

Job Industries

• Other