Claims Analyst

Position Summary:

The Claims Analyst processes claims in accordance with established policies and procedures. This key individual incorporates and assures quality production principles in all areas of the Claims Department.

Essential Functions:

1. Processes claims utilizing data entry and adjudication; executes claims' adjustments when needed.

2. Maintains a thorough knowledge of provider contractual issues and summarizes plan documents for each assigned accounts.

3. Identifies possible coordination of benefits (COB) coverage if applicable.

4. Follows claim processing guidelines to obtain all necessary information for accurate and timely processing. Processes routine claims adjustments either electronically or manually while maintaining daily productivity rating. Receives and validates claims from internal and external clients.

5. Collaborates with duties related to the claim audit process, this includes but is not limited to claim analysis, site visits, document preparation and proper file storage.

6. Maintains overall quality, accuracy of financial, and procedure aspects of operation.

7. Receives and processes correspondence when needed.

8. Collaborates with new hire training when needed.

Other Duties:

• Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable.
• In addition, all other duties assigned by the manager and/or supervisor.

Education:

• High School diploma.
• Degree in Data Entry or related preferred.

Experience:

• Minimum 1 year of experience in similar position or data entry.

Knowledge:

• Knowledge of Microsoft Office including Excel, Word and PowerPoint.