Analista de Reclamaciones III

Analista de Reclamaciones III

Regular

Non-Exempt

GENERAL DESCRIPTION

Analyzes, processes, and adjudicates all types of complex claims submitted in Centers for Medicare and Medicaid Services Form 1500 (CMS‑1500) and Uniform Billing Form 04 (UB‑04) formats, applying the highest level of analytical judgment to determine appropriate payment or denial. This includes the evaluation of adjustments, member reimbursements, grievances, reconciliations, Coordination of Benefits (COB), United States claims, non‑participating provider claims, recoveries, reinsurance, life insurance claims, and other specialized transactions. Requests additional information, when necessary, in accordance with applicable benefits and policy requirements, and within the maximum adjudication authority limit established by current policy and procedure.

ESSENTIAL FUNCTIONS

• Processes complex claims, including adjustments, COB, samplings, United States claims, non‑participating provider claims, grievances, member reimbursements, multiple categories of adjustments, reconciliations, recoveries, reinsurance, and life insurance claims, among other specialized transactions.
• Evaluates and resolves claims referred from prior authorization levels and determines when analyzed claims require additional support, coordination, or intervention from other departments.
• Refers claims and/or adjustments to the necessary departments to obtain additional information, support outreach efforts, or secure the required approvals for payment adjudication or denial decisions.
• Reports any evidence of unusual utilization patterns, suspected attempted fraud, or irregular claim activity detected during the adjudication process to the appropriate department and immediate supervisor.
• Reports to the immediate supervisor any evidence of deficiencies in system configuration, contract coverage setup, or provider agreement discrepancies identified during claim adjudication.
• Reports any identified errors in payment or denial patterns to the appropriate department and the immediate supervisor to ensure prompt correction and system integrity.
• Executes the average number of claims established by the company (subject to change), maintaining required financial accuracy and compliance with current policies and procedures.
• Complies with and continuously update their individual productivity report as required by departmental guidelines.
• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS

Education and Experience: Bachelor's Degree. At least two (2) years of experience in claims processing and adjudication, applying payment policies, fee schedules, and coding guidelines, or in a Provider Call Center in the Health Insurance Industry.

OR

Education and Experience: Associate's Degree or at least sixty to sixty-four (60-64) approved college credits. At least three (3) years of experience in claims processing and adjudication, applying payment policies, fee schedules, and coding guidelines, or in a Provider Call Center in the Health Insurance Industry.

OR

Education and Experience: High School Diploma or Technical Course. At least four (4) years of experience in claims processing and adjudication, applying payment policies, fee schedules, and coding guidelines, or in a Provider Call Center in the Health Insurance Industry.

"Proven experience may be replaced by previously established requirements."

Certifications/Licenses: N/A

Other: Expertise in managing and interpreting the Current Procedural Terminology, Fourth Edition (CPT‑4), International Classification of Diseases, Tenth Revision (ICD‑10), and Healthcare Common Procedure Coding System (HCPCS) coding manuals to ensure accurate claim adjudication and processing. Knowledge of payment rules, medical terminology, and standardized healthcare coding systems.

Languages:
Spanish – Intermediate (comprehensive, writing, and verbal)
English – Intermediate (comprehensive, writing, and verbal)

“We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.”