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.
Skills:
Knowledge of general claim processing.
Knowledge of Medical terminology, CPT, and DSMV coding.
Strong verbal and written communication skills.
Strong analytical skills with demonstrated ability to problem solve.
Consultative selling skills and experience with ability to translate customer needs to sales opportunities.
Professional verbal and written communication skills, with the ability to clearly articulate thoughts and ideas.
Organizational skills with the ability to handle multiple tasks and/or projects at one time.
Time management skills with the ability to prioritize and schedule daily activities for the most efficient use of time.
Problem solving skills with the ability to look for root causes and implement, workable solutions.
Interpersonal skills with the ability to work in a fast-paced environment and participate as an independent contributor with little supervision or as an active team member depending on the situation and needs.
Must have a record of accomplishment of producing work that is highly accurate, demonstrates attention to detail, and reflects well on the organization.
