CLAIMS ANALYST

Position Overview: As a Medical Claims Analyst youll be responsible for determining eligibility of claims under major medical and self-insured plans, investigating charges, explaining payment or denials to claimants, and more.

Key Responsibilities:

• Communicates internally & externally with clients, participants, brokers, agents, & more
• Analyzes claims to determine eligibility, medical facts, contract coverage & limitations
• Determines when to pay or deny claims, or request additional information
• Calculates payment of benefits in accordance with coverage information, contract language or plan document & medical documentation
• Screens all charges for reasonableness of costs & medical necessity
• Investigates excess or questionable charges by letter or telephone
• Determines possibility of coordination of benefits (COB) on each claim & calculates benefits accordingly
• Coordinates with member advocates to contact providers, members, and others in regard to claims, additional information, eligibility, and additional issues affecting claims adjudication
• Additional responsibilities as assigned based on client and business needs

Qualifications:

• High school diploma or equivalent
• Experience & education may be substituted for one another

• Knowledge of CPT, HCPCS, IC10 coding
• Knowledge of claims processing & the Eldorado system (preferred)
• Skilled in customer service, with strong communication skills (interpersonal & written)
• Good at problem solving and analyzing information
• Comfortable with software and technology and willing to learn new systems
• Able to adapt to a constantly changing environment & multitask
• Able to accurately compile data, perform detailed work & maintain confidential information
• Able to meet deadlines
• Able to maintain attendance & present a professional appearance & demeanor
• Able to work well with others

Qualifications:

• High school diploma or equivalent
• Experience & education may be substituted for one another
• Knowledge of CPT, HCPCS, IC10 coding
• Knowledge of claims processing & the Eldorado system (preferred)
• Skilled in customer service, with strong communication skills (interpersonal & written)
• Good at problem solving and analyzing information
• Comfortable with software and technology and willing to learn new systems
• Able to adapt to a constantly changing environment & multitask
• Able to accurately compile data, perform detailed work & maintain confidential information
• Able to meet deadlines
• Able to maintain attendance & present a professional appearance & demeanor
• Able to work well with others

Work Environment / Physical Requirements

• Must be able to remain in a stationary position for 80% of the time.
• Must use close visual acuity to perform an activity such as: preparing and analyzing data and figures, transcribing, viewing a computer terminal and expansive reading.
• Must be able to lift or move items up to 20lbs.
• Must have the ability to move files, open filing cabinets and bend or stand as necessary.