Claims Analyst

Description:

Full-Time (40 hours) Responsible for reviewing and investigating healthcare insurance claims to determine appropriate contractual payments and adjustments, validity and accuracy Functions of the Position (not an exhaustive list): Investigate claims: Research and evaluate claims for legitimacy and accuracy, which may involve gathering additional information from other parties including payers, providers and other departments

Contract Management Platform:

Use and maintenance of existing contract management software, including uploading, maintaining and removal of payer contracts.

Reporting:

Maintaining, analyzing and providing reporting metrics related to payer reimbursement data in a timely and predictable manner Process claims: Analyze insurance claims according to policy provisions and guidelines Determine eligibility: Interpret complex policy language and provisions to determine coverage and appropriate reimbursement amounts Detect fraud: Analyze claim data and identify irregularities or patterns that may indicate fraudulent activity

Requirements:

Qualification 1.

Education:

High School diploma or equivalent Hospital billing experience preferred 2.

Physical Demands:

Requires sitting for long periods; sometimes in a confined space Lifting/carry up to 20lbs Repetitive finger movement Manual dexterity and mobility Reaching at all levels Stooping, bending, kneeling, crouching Work with machinery with moving parts 3.

Experience:

Previous experience in claims processing or medical billing preferred Knowledge of policies and regulations: Strong understanding of insurance policies, coverage limitations, and industry-specific regulations (e.g., HIPAA for health claims) Claims management software: Proficiency with claims processing and management software Data analysis: Ability to collect, analyze, and interpret claims data using tools like Microsoft Excel and other databases Medical terminology: Familiarity with medical codes (CPT-4 and ICD-10) for health claims and basic legal principles.