CLAIMS ANALYST III

Job Summary:

The Claims Analyst III is responsible for all priority projects from external providers and internal resources within the organization, and for pre-check reports. This individual is responsible for the Provider-On-Boarding program, and for the accurate and timely processing of moderate to complex claims including high dollar claims and adjustments to previously processed claims. The Claims Analyst III will conduct all pertinent research in order to evaluate, respond and close incoming Provider Disputes Resolution claims accurately, timely and in accordance with all established regulatory guidelines. In addition to interacting with internal departments and external resources and organizations and providing claim adjudication assistance as directed by the Claims Supervisor.

Responsibilities:

• Reviews and takes appropriate action on priority projects from internal resources as well as external customers.
• Evaluates and performs batch processing within the core system.
• Reviews and signs off on all pre-check reports.
• Reviews, researches and validates the configuration of the provider on boarding program.
• Evaluates and processes claims and claim adjustments in accordance with company policies and procedures according to productivity and quality standards.
• Proofs claim or referral submissions to determine, review, or apply appropriate guidelines, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements.
• Interprets and processes moderate to complex claims including high dollar claims.
• Checks for erroneous items or codes and missing information and correct according to established procedures.
• Reviews and analyzes data from system-generated reports for in-process claims in order to identify and resolve errors prior to final adjudication.
• Alerts claims management to claims aging issues as well as provider billing problems.
• Maintains current knowledge of members' benefits, policies/procedures, provider network development and contract issues, processing system issues, Medi-Cal regulations, as well as industry standards for claims adjudication.
• Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies.
• Researches, evaluates and compiles necessary supporting documentation for provider disputed claims.
• Researches Provider Disputes submitted by contracted and non-contracted providers to identify original paid or underpaid claims.
• Responds to incoming Provider Disputes accurately.
• Tracks denial or payment variance trends and escalates to department management as appropriate for training opportunities and corrective action.
• Tracks, follow up and manage submitted PDRs relating to medical necessity. Works closely with appropriate clinical staff for proper resolution determination.
• Evaluates and processes assigned customer service tickets.
• Maintains established claims production standards.
• Consistently meets quality standards.
• Performs other related duties consistent with the scope and intent of the position.
• Regular attendance.
• Travel as required.

Other Functions

• Enforces Company policies and safety procedures.
• Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.
• Maintain IPA, Health Plan compliance standards.

Competencies

• Minimum two (2) years of claims adjudication and/or Provider Dispute Resolution adjudication at Vivant or equivalent experience.
• Minimum two (2) years or more in managed care claims processing claims.
• Two years (2) HMO/IPA experience required.
• Two (2) years’ experience with ICD-9/10, HCPCS, CPT coding, modifiers, DMHC regulations, facility and professional claim billing practices.
• One (1) year experience with Provider Dispute Resolution.
• Ability to maintain production level and quality goals based on department needs.
• Work product demonstrates excellent attention to detail, is accurate, thorough and effective.
• Excellent communication skills, including both oral and written.
• Strong analytical skills.
• Excellent active listening and critical thinking skills.
• Ability to solve mid-level to complex problems with minimal supervision.
• Ability to demonstrate professionalism, confidence, and sincerity while quickly and positively engaging providers.
• Ability to multi-task, exercise excellent time management, and meet multiple deadlines.
• Demonstrate excellence in organization.
• Ability to provide and receive constructive job and/or industry related feedback.
• Ability to maintain confidentiality and appropriately share information on a need-to-know basis.
• Ability to consistently deliver excellent customer service.
• Ability to effectively and positively work in a dynamic, fast-paced team environment and achieve objectives.
• Demonstrate commitment to the organization’s mission.
• Must have mid-level skills in Microsoft software (Word, Excel, and PowerPoint, Outlook).
• Must have the ability to quickly learn and use new software tools.
• Must have mid-level skills using e-mail applications.
• Ability to work independently as well as in a team environment.
• Ability to present self in a professional manner and represent the Company image.

Education and Licensure

• High School Diploma or GED minimum requirement.
• Associate’s degree preferred.

Travel

• The incumbent may travel up to 5% of the time.

Supervisor Responsibility

• This position supervises several employees in multiple disciplines: list
• This position does not have any supervisor responsibilities.

Work Environment

This job operates in a professional office environment. This role routinely uses office equipment such as computers, phones, photocopiers, scanners and filing cabinets.

Mental and Physical Demands

Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the position. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing this job, the employee is regularly required to talk and hear. The employee frequently is required to sit, stand; walk; use hands to finger, handle, or feel; and reach with hand and arms. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus. Experiences frequent interruptions; required to meet inflexible deadlines; requires concentration and attention to detail; requires a high level of organizational and prioritization skills. May be required to sit for prolonged periods; exposed to visual display terminal for prolonged periods; dexterity and precision required in the operation of a computer.