Claims Investigation Analyst I

Responsible for the review and resolution of complex claims issues, using established state and federal guidelines, departmental policies, and procedures ensuring that the work is performed accurately and delivered to meet set objectives. Act as the liaison between the BPO and Community Health Plan of Washington business units for the resolution of claims issues. Responsible for follow up with providers, internal and external vendors to ensure resolution is communicated to impacted parties.

To be successful in this role, you:

• Have a minimum of 2 years’ experience in a healthcare/insurance setting or provider billing setting resolving complex claims required.
• Have Medicaid and Medicare experience required.
• Have experience with HCA and CMS billing guidelines.
• Have a high school diploma or GED preferred, but not required.

Essential functions and Roles and Responsibilities:

• Receive phone calls, emails, and faxes from providers and respond appropriately as well as assess appeals and determine appropriate action.
• Act as the technical claims expert, following state and federal guidelines, and Community Health Plan of Washington provider contracts.
• Accurately evaluate, analyze, and resolve complex claims and provider billing issues in a timely manner and according to set standards.
• Collaborates and coordinates with BPO Operations to ensure accurate interpretation of billing guidelines, contract benefits, exclusions, and limitations, and escalate as necessary.
• Assist in optimizing workflows, troubleshooting and problem solving to insure corporate goals are met.
• Respond accurately and courteously to provider inquiries or internal parties regarding benefit interpretation, eligibility, claims status, accessing care through plan providers, and other related issues.
• Commitment to a philosophy that supports single contact resolution.
• Identify and initiate claims processing adjustments as needed.
• Utilize all resources both internal and external and apply that knowledge to improve efficiency and accurately respond to inquiries.
• Meet quality standards.

Knowledge, Skills, and Abilities:

Ability to gather data, analyze, and summarize results.

• Ability to perform a variety of complex tasks, included but not limited to claims, pricing methodology, denials, authorizations, and vendor inquiries.
• Ability to collaborate with others and work effectively in a team environment.
• Ability to take initiative to plan and complete assigned work with a high level of accuracy.
• Problem solving and research skills.
• Ability to comprehend and work efficiently with systems of high complexity.
• Ability to organize and prioritize tasks.
• Detail oriented
• Oral and written communication skills.
• Proficient in Microsoft Office Suite.

As part of our hiring process, the following criteria must be met: 

• Complete and successfully pass a criminal background check.

Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.

• Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
• Vaccination requirement (CHPW offers a process for medical or religious exemptions)
• Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

Compensation and Benefits:

The position is FLSA Non-Exempt and is eligible for overtime and has a 5% annual incentive target based on company, department, and individual performance goals. The base pay actually offered will take into account internal equity and also may vary depending on the candidate’s job-related knowledge, skills, and experience among other factors.

CHPW offers the following benefits for Full and Part-time employees and their dependents: 

•  Medical, Prescription, Dental, and Vision
•  Telehealth app
•  Flexible Spending Accounts, Health Savings Accounts
•  Basic Life AD&D, Short and Long-Term Disability
•  Voluntary Life, Critical Care, and Long-Term Care Insurance
•  401(k) Retirement and generous employer match
•  Employee Assistance Program and Mental Fitness app
•  Financial Coaching, Identity Theft Protection
•  Time off including PTO accrual starting at 17 days per year
•  40 hours Community Service volunteer time
•  10 standard holidays, 2 floating holidays
•  Compassion time off, jury duty

Sensory/Physical/Mental Requirements:

Sensory*:

• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical*:

• Extended periods of sitting, computer use, talking and possibly standing
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion
• Frequent torso/back static position; occasional stooping, bending, and twisting.

Mental:  

• Ability to learn and prioritize multiple tasks at a given time and have the capability of handling demanding situations. Analytical/problem solving/critical thinking ability.

Work Environment:

Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.