Claims Processing Analyst I

GENERAL PURPOSE OF JOB
The Claims Processing Analyst performs claims analysis and associated responsibilities in
support of claims administration, and performs other related work as required.

ESSENTIAL DUTIES AND RESPONSIBILITIES - Positions in this class may perform any or all
of the below listed duties. These should be interpreted as examples of the work, and are not
necessarily all-inclusive.
1. Validate submitted claims data to ensure accuracy, validity and integrity.
2. Analyze pended claims, collaborating with internal business partners for necessary information and assistance, according to departmental procedures.
3. Effectively prioritize and complete all assigned tasks within appropriate timeframes and with required level of quality.
4. Evaluate claims issues and procedures to identify and suggest opportunities for improvement, both in efficiency and quality.
5. Openly participate in team meetings, providing ideas and suggestions to ensure departmental best practices, and to develop and promote teamwork.
6. Maintain required compliance with privacy and confidentiality standards.
7. Maintain or exceed all established standards for performance, quality and timeliness.
8. Support the Claims department in review, investigation, and research of claims issues and completion of claims projects.
9. Communicate effectively, in verbal or written form, by sharing ideas and reporting facts and issues.

10. Demonstrate business practices and personal actions that are ethical and adhere to all Health System and Health Plan policies and procedures.
11. Assist with other related work responsibilities as requested

EDUCATION AND/OR EXPERIENCE - Any combination of education and experience that would likely provide the required knowledge, skills, and abilities is qualifying work.

Minimum of two years professional experience in claims analysis, provider medical billing, or medical coding.

High School graduate or GED required.

Experience with Microsoft Excel and Word as well as with medical terminology, coding and billing concepts.

Experience with health insurance and managed care principles.

Ability to work independently, or in a team environment, toward meeting common goals.

Integrity and discretion to maintain confidentiality of member and provider data.
Ability to apply mid-level concepts of claims adjudication, following established procedures and workflows for completion of assigned task.
Ability to multi-task and meet deadlines in a fast-paced environment
in a fast-paced environment.