Claims Analyst

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

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.