DEPARTMENT:  Operations

REPORTS TO: Claims Operations Team Lead

HOURS:  37.5  

FLSA: Non-Exempt   

SALARY GRADE:    9

 

Overview:

 

The role of the Claims Analyst is to ensure that claims are processed according to state and federal regulations and meet NHPRI’s contractual obligations. 

 

Qualifications:

 

Required:

- High school graduate or equivalent

- Demonstrated knowledge of industry standard coding and medical terminology

- 3 - 5 years claims processing or medical billing experience is required with 1 year minimum experience as claims analyst/examiner

- Demonstrated ability to meet production standards with quality

- Demonstrated ability to effectively prioritize and execute tasks in a production environment

- Demonstrated ability working with Microsoft Word and Excel

- Strong verbal and written communications skills

- Demonstrated Mathematical skills and detail accuracy

- Ability to work both independently and as a team member

Preferred:

- Some College or Bachelor’s Degree

- Related Professional Training and/or Certifications

- Prior experience within a claims operations area in a Health Care environment

 

 

Duties and Responsibilities:

Responsibilities include, but are not limited to the following:  

 

- Responsible for the entry, review and adjustment of claims within the claims transactional system, according to plan benefits and contractual reimbursement terms

- Meet minimum production and quality standards as established by Team Leader, Manager and Director of Operations.

- Responsible for reviewing and resolving daily claims adjudication reports resulting from EDI claims entry

- Review, investigate and release low to high complexity claims

- Responsible for the data integrity and accuracy of manually entered claims

- Responsible for generating requests for additional information required to process a claim (i.e., incomplete authorization information, requesting a new provider number)

- Resolve any personal data integrity error reports

- Responsible to determine if correct billing/coding requirements have been met

- Process claims subject to COB (Co-ordination of Benefits) according to plan benefits, COB rules and contractual reimbursement terms

- Responsible for the processing of member refunds, employee claims and transplant cases

- Retroactive adjustment projects, as assigned

- Support various claims scanning functions, as necessary

- Support claim batching process as needed

- Daily analysis of workflow to meet targets, including distribution of workflow

- Identify and communicate claims system and/or billing problems to the Team Leader and/or Manager

- Complete daily activity logs as required

- Assist in training of other claims staff

- Special projects as assigned

To apply, please visit:http://www.nhpri.org/matriarch/MultiPiecePage.asp_Q_PageID_E_185_A_PageName_E_CareersIntroPage