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Senior Claims Analyst

Amalgamated Life Insurance White Plains Full-Time
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The Senior Claims Analyst is responsible for handling complex claims and all adjustment types, including check maintenance functions, JAA adjustments, and is responsible for providing  claims technical and analytical support to the claims department.  

  • Handle and process all claim and benefit types for all groups/plans  requiring detailed analysis for coverage and claim determination. 
  • Accurately handle and process all claim adjustment types, maintaining timely turnaround.
  • Review and research complex claims, provide necessary feedback to other analysts, and/or complete the handling.
  • Review  customer service and service executive referrals for root cause issues, document and bring to resolution.
  • Review correspondence as assigned and bring to resolution.
  • Understand the Anthem JAA product and workflow, handle and monitor JAA adjustments,  resolve 837 claim failures and assist with aged inventory review.
  • Manage and respond to Anthem JAA customer service mailbox/inquiries, taking appropriate steps to resolve and follow up within required timeframes.
  • Troubleshoot any referred cases, including contact with AMM or other UR vendor, provider relations, Anthem,  and any other required inter-departmental and external personnel.  
  • Perform necessary investigations, including COB, No-fault, pre-existing, subrogation.
  • Utilize training and on-line documentation to keep up to date on processing & adjustment guidelines, insurance principles, DOL rules and regulations, and benefit plan rules.
  • Identify overpayments, perform claim system transactions, send letters, and record recoveries in appropriate database.  
  • Manage the monthly check maintenance functions, including  refunds, voids, stale date review, Anthem voids,  and complete the necessary transactions.
  • Update claims system with applicable claim/and patient notes.
  • Assist with QA of claims and any other assigned projects, as needed.
  • Contact employers, providers, members as needed to bring case to resolution.
  • Utilize workflow to manage work and maintain daily production document. 
  • Handle other claim-related duties, projects and assignments, as assigned.  

  • One to two years of college or equivalent experience.
  • Minimum of three (3) or more years experience as a specialist analyst or five (5) or  more years experience as a production analyst, meeting production and quality  goals/ standards. 
  • Current experience processing medical and hospital claims on Eldorado Claims system.
  • Requires NYS Accident & Health Adjuster License.  
  • Knowledge of insurance and medical claim terminology.
  • High level of keyboard/PC skills.
  • Excellent oral and written communication skills.
  • Good judgment and decision- making abilities.
  • Good analytical and math skills.
  • Good interpersonal skills and willingness to assist others.
  • Basic knowledge of Word and Excel.

Recommended skills

Product Quality Assurance
Interpersonal Skills
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