Claims Analyst

Claims AnalystPosition Type Full Time Category InsuranceDescriptionJob Title: Claims AnalystReports To: Supervisor of ClaimsThis is a non-exempt position responsible for reviewing, analyzing, and adjudicating non-routine health claims that could not be system adjudicated for payment. Analyst must research and interpret summary plan description language and make accurate determination for adjudication or denial of claim. Analyst must also assist in determining cause for manual intervention, then assist in writing logic and workflow automation for future claims.Brief Description of Duties:Review incoming medical, pharmacy vision and dental claimsDetermine and apply appropriate health plan benefits and update claims for paymentEnsure timely and accurate claims adjudicationFollow company guidelines and policies for adjudicating claims and responding to membersAct as a resource for questions, opportunities, and research issues for all internal and external customersResponsible for meeting performance measurement standards for productivity and accuracyIdentify and resolve operational problems using defend processes, judgment, and expertiseProvide feedback to team members regarding process improvement opportunitiesAssist with training and mentoring of new team membersResolve identified claims issues based on CCI edit report to comply with CMS guidelines.Represent the department when needed for internal and external company meetingsComplete special projects (including research) as assigned by Claims Supervisor or Director of ClaimsHigh level understanding of state and federal laws specific to health plan administration (HIPAA, ERISA, MHPAEA, ACA Mandates etc.)Develop and maintain statistical data as requiredAssist in departmental reportingQualificationsMinimum Skills Requirement:Post-secondary education or two years experience in a claims processing environmentExperience in Medicare Advantage strongly preferredExcellent communications (oral and written) skillsIntermediate skill levels in Microsoft Word, Excel, and Outlook preferredAbility to work at a self-directed pace in a changing, multi-task environmentDetail orientedProfessional appearance and presenceCommitment to support and maintain confidentiality in conformance to HIPAA guidelinesOther:Confirmation of excellent attendance record in current or most recent jobGeneral knowledge and understanding of claims processing functions