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Summary:
- The Claims Analyst is responsible for monitoring liability claims, verifying and updating information on submitted claims.
- Reviews contract information and policies to determine which charges are eligible for reimbursement.
- Ensures completeness and accuracy with claims processing to support the organization’s revenue cycle.
Responsibilities:
- Reviews claims and appeals for accuracy, completeness, and eligibility.
- Analyzes and audits claims to ensure compliance and provides solutions to resolve claims errors.
- Creates financial estimates on a weekly basis using Microsoft Excel.
- Provides feedback and justification of denied claims to providers, as needed.
- Aids providers on how to submit claims and verify participant eligibility.
- Conducts basic contract review to confirm payment rates.
- Collaborates with other departments in the organization.
- Requests monthly inventory tracker from TPA (Third Party Administrator).
- Conducts follow-up activity for claims held until the claim is closed.
- Confirms that claims are associated with pre-authorizations from the Interdisciplinary Team (IDT) and/or Primary Care Provider.
- Conducts coordination of benefits, ensuring that claims impact primary and secondary insurance, as appropriate.
- Reviews and analyzes claims loss, expense reserves, and reconciles claims reports with authorization sheets.
- Processes new claims and disseminates them to TPA.
- Reports claims issues to IDT, Primary Care Providers, Vice President of Finance, and other entities, as appropriate.
- Assists Claims Supervisor to identify exposures to the company and reports to senior-level management on pending claims and litigation that may have an adverse impact on corporate goals.
- Assists Claims Supervisor as a liaison between the TPA, provider network, insurance companies, and other entities as needed.
- Checks pricing of claims through contracted rates and Medicare/Medicaid fee schedules.
- Demonstrates workplace behavior that promotes organizational core values of honesty and integrity, respect for others, encouragement, high-quality care, and patient-centeredness.
- Attends and participates in staff meetings, in-services, projects, and committees as assigned.
- Adheres to and supports the center’s practices, procedures, and policies, including assigned break times and attendance.
- Accepts assigned duties in a cooperative manner; and performs all other related duties as assigned.
- Is flexible in the schedule of hours worked.
- May be required to use a personal vehicle, if applicable. A valid California Driver’s License is required if using a personal vehicle.
Requirements:
- Proficient knowledge of computer skills. MS Office (Word, Excel, Access, PowerPoint, Publisher, and Outlook). Candidates will take a Microsoft Office proficiency exam before being offered a position.
- Strong organizational skills that reflect the ability to perform and prioritize multiple tasks seamlessly with excellent attention to detail.
- Excellent written, grammatical, reading comprehension, and verbal skills required.
- Ability to quickly learn department policies, procedures, goals, and services.
- Skill: Attention to detail and accuracy.
- Ability to change priorities regularly.
- Ability to access all areas of the center throughout the workday.
- Ability to lift a minimum of 35 pounds occasionally, 15 pounds frequently, and 7 pounds constantly; required to obtain assistance from another qualified employee when attempting to lift or transfer objects over 50 pounds.
- Requires constant hand grasp and finger dexterity; frequent sitting, standing, walking, and repetitive leg and arm movements, occasional bending, reaching forward and overhead; squatting and kneeling.
- Work is generally performed in an indoor, well-lighted, well-ventilated, heated, and air-conditioned environment.
