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.

Claims Analyst I: In this position, individuals perform the full range of assigned tasks under supervision, while exercising discretion and independent judgment within established procedures.  Examples of responsibilities include:

Claim review of simple to moderate complexity

Provider contract pricing

Independent analysis

Assistance with special projects

Validate submitted claims data to ensure accuracy, validity, and integrity.

Analyze pending claims, collaborating with internal business partners for necessary information and assistance, according to departmental procedures.

Effectively prioritize and complete all assigned tasks within appropriate timeframes and with required level of quality.

Evaluate claims issues and procedures to identify and suggest opportunities for improvement, both in efficiency and quality.

Openly participate in team meetings, providing ideas and suggestions to ensure departmental best practices, and to develop and promote teamwork.

Maintain required compliance with privacy and confidentiality standards.

Maintain or exceed all established standards for performance, quality, and timeliness.

Support the Claims department in review, investigation, and research of claims issues and completion of claims projects.

Communicate effectively, in verbal or written form, by sharing ideas and reporting facts and issues.

Demonstrate business practices and personal actions that are ethical and adhere to all Health System and Health Plan policies and procedures.

Assist with other related work responsibilities as requested.

ESSENTIAL DUTIES AND RESPONSIBILITIES - Positions in this class may perform any or all the duties below listed. 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 pending 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.

High school graduate or GED required

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

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 tasks.
Ability to multi-task and meet deadlines in a fast-paced environment.