Claims Investigation Analyst Ii

2 weeks ago

Danville, United States Geisinger Full time

**Job Summary**: Reviews and resolves complex claims issues, using established state and federal guidelines, departmental policies and procedures to ensure that work is performed accurately and delivered to meet set objectives. Acts as a liaison between the provider and other Health Plan departments and facilitates the exchange of information between the grievances, claims processing and provider relations systems. Follows up with providers, internal and external vendors to ensure resolution is communicated to impacted parties.

**Job Duties**:

- Acts as the technical claims expert, following state and federal guidelines and provider contracts.
- Educates contracted and non-contracted providers regarding appropriate claims submission requirements, coding updates, electronic claims transactions and electronic fund transfer and available resources such as provider manuals, websites, fee schedules, etc.
- Provides on-site professional guidance as needed to facilitate issue resolution.
- Evaluates and resolves complex claim and provider billing issues in a timely manner and according to set standards.
- Coordinates with the provider, as needed, in alignment with the Account Management team, on claims processing issues and provides follow-up to all impacted parties.
- Works with the customer service team to ensure accurate interpretation of billing guidelines, member benefits, contract terms, exclusions and limitations; escalates as necessary.
- Interfaces with the call center to compile, analyze and disseminate information from provider calls.
- Provides feedback to the configuration team to ensure payment terms are set-up correctly.
- Assists with completion of claims audits to ensure accurate payments to providers.
- Responds to provider inquiries regarding claims payments.
- Communicates with providers to gain feedback regarding the extent to which providers are informed about appropriate claims submission practices.
- Provides information and facilitates and coordinates appropriate resolution of issues and complaints.
- Documents inquires, complaints and other data in all applicable systems in an accurate, clear and timely manner.
- Identifies trends and develops ways to streamline and simplify internal processes as necessary to reduce turnaround times and improve data quality and provider satisfaction.
- Initiates process improvement projects resulting from operational concerns.

Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
- Relevant experience may be a combination of related work experience and degree obtained (Associate’s Degree = 2 years; Bachelor’s Degree = 4 years).

**Position Details**:
**PREFERRED EXPERIENCE**:
**Facets claims and working with provider offices**

**Internet requirements**:
***Employee required to have/supply: Cable modem, (high speed, only - No DSL or Wireless Cellular Service or Satellite Service) The minimum requirement is:

- 5 MBPS UP
- 20 Mbps DOWN
-

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