Claims Review Analyst

Summary of Position

Support contract performance management of a large health system.
Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on contractual and industry guidelines.
Identify and analyze single issues and trends to determine root causes.
Provide recommendations for solutions to minimize errors and delays in systems and/or processes.
Monitor system output to ensure proper functioning.

Principal Accountabilities

Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims review.
Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is returned to the provider timely.
Track issues and monitor trends to support their resolution.
Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management.
Improve quality, enhance workflow, and provide efficiencies within departments, identify opportunities for improvements; develop and present recommendations for changes.
Conduct regular meetings with the assigned provider groups for status of AR files and recycles
Support departmental goals for cycle time by organizing and tracking claims for review.
Monitor and provide timely responses for the designated provider group emails and AR files.
Perform other related tasks as directed or required.

Qualifications

Education, Training, Licenses, Certifications

Relevant Work Experience, Knowledge, Skills, and Abilities

2 – 3 years’ prior related work experience in professional/facility claims or benefits/billing environment.
Additional experience/specialized training may be considered in lieu of educational requirements.
Strong knowledge of claim processing policies and procedures.
Knowledge of medical terminology, ICD/CPT coding, per diem and DRG reimbursement and EDP testing procedures.
Proficiency with MS Office applications (word processing, database/spreadsheet, presentation).
Ability to accurately interpret information from contractual and technical perspectives.
Must be conscientious and detail oriented; ability to recognize unusual patterns and troubleshoot for operational improvement and efficiencies.
Strong analytical and problem-solving skills.
Ability to effectively work on multiple projects/tasks with competing priority levels and deadlines.
Ability to effectively absorb and communicate information.
Strong Interpersonal and teamwork skills.

Additional Information

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