Claims Processing Analyst II

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.

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

• Claim review/analysis of moderate to advanced complexity

• Complex provider contract pricing

• High dollars claim review

• Claim research

• Claim issue resolution

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Positions in this class may perform any or all duties listed.  These should be interpreted as examples of the work and are not necessarily all-inclusive.

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

• Analyze pending claims and collaborate 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 the 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 confidentially 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.

EDUCATION AND/OR EXPERIENCE:

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

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

• Advanced experience with health insurance and managed care principles.

• Experience with Complex claims analysis and resolution.