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Claims Analyst
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TurningPoint Healthcare Solutions is disrupting the traditional approach to specialty care management through innovative technology and world-class clinical expertise.
Founded in 2014, TurningPoint has built a team of 400 leading healthcare experts, clinicians, and technologists helping customers in 33 states manage the health and wellness of 26M patient lives and $4B in medical expenditures each year. TurningPoint empowers health plans and providers to improve the quality, safety, and affordability of healthcare.
TurningPoint specializes in treating the most complex areas of care management including musculoskeletal, pain management, cardiology, wound care, oncology, ear/nose/throat, sleep, and implantable devices. Leveraging data analytics, AI, and machine learning as well as the latest advancements in telemedicine solutions, TurningPoint brings patients, providers, and health plans together to manage risk, lower costs, and drive better outcomes.
Position Summary:
The Claims Analyst is responsible for the analysis of claims data to identify any potential adjudication recommendations or recoupment opportunities on behalf of the Health Plan clients.
Roles and Responsibilities:
- Analyze surgical claims data from physicians and facilities for coding and charge accuracy
- Request medical records to support additional research and review of the claim
- Process and prepare medical records for clinical review by a nurse or physician
- Review implant configurations for coding and unit accuracy
- Manage all reviews and medical record requests within timeframes per service level agreements.
- Utilize client specific medical and reimbursement policies to determine appropriateness of claim and whether the procedure is covered under the members health benefit plan.
- Identify and aggregate provider information for providers who are consistently submitting inaccurate and or fraudulent claims to Health Plan.
- Receive and respond to telephone calls and inquiries from providers and/or Health Plan clients
- Maintain documentation on status of activity and communication of outcome
- Respect and maintain HIPAA, PHI and company confidentiality guidelines
- Other duties as directed
Education, Experience and Licensure:
- High School Diploma or equivalent is required. Associate’s or Bachelor’s Degree in Healthcare or related field
- Minimum of 2 years’ experience in Customer Service, or any healthcare operations
- 5+ years claim processing experience and demonstrated ability to handle multiple assignments competently, accurately and efficiently.
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