Claims Review Analyst

Summary of Position

• Support contract performance management of a large health system.

• Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on contractual and industry guidelines.

• Identify and analyze single issues and trends to determine root causes.

• Provide recommendations for solutions to minimize errors and delays in systems and/or processes.

• Monitor system output to ensure proper functioning.

Roles and Responsibilities

• Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims review.

• Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is returned to the provider timely.

• Track issues and monitor trends to support their resolution.

• Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management.

• Improve quality, enhance workflow, and provide efficiencies within departments, identify opportunities for improvements; develop and present recommendations for changes.

• Conduct regular meetings with the assigned provider groups for status of AR files and recycles

• Support departmental goals for cycle time by organizing and tracking claims for review.

• Monitor and provide timely responses for the designated provider group emails and AR files.

• Perform other related tasks as directed or required.

Qualifications

• Bachelor's Degree; additional experience/specialized training may be considered in lieu of educational requirements.

• 2 - 3 years' prior related work experience in professional/facility claims or benefits/billing environment.

• Strong knowledge of claim processing policies and procedures.

• Knowledge of medical terminology, ICD/CPT coding, per diem and DRG reimbursement and EDP testing procedures.

• Proficiency with MS Office applications (word processing, database/spreadsheet, presentation).

• Ability to accurately interpret information from contractual and technical perspectives.

• Must be conscientious and detail oriented; ability to recognize unusual patterns and troubleshoot for operational improvement and efficiencies.

• Strong analytical and problem-solving skills.

• Ability to effectively work on multiple projects/tasks with competing priority levels and deadlines.

• Ability to effectively absorb and communicate information.

• Strong Interpersonal and teamwork skills.

Additional Information

• Requisition ID: 2603P
• Hiring Range: $48,600-$83,160