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Analyst, Claims

2 months ago

Phoenix, United States Tangocare Full time

Brief Description

The Claims Analyst is accountable for and oversees the following tasks:

Processes all “unclean” claims adhering to claims policies and procedures Confirm reimbursement accuracy upon approving per the Provider Contracts or SCA/LOA agreements on file when processing claims Analyze claims EOB pend/denial codes and troubleshoot why claim was unclean and collaborate with Claims Customer Service Analysts to educate the provider on claims submission errors Perform claims reprocessing as assigned Assist with special reports of processing claim reports and fixing eligibility and authorization mismatches accurately and timely Apply knowledge of coding in order to determine if claim should be denied or approved per claims policies Review documentation, analyze submitted claims data with an average of 95% accuracy monthly Escalate any system issues or roadblocks that prevent hitting claim metrics as applicable

Essential Job Functions And Duties

Processing claims within the Claims Policies at 95% accuracy and meeting productivity standards as outlined Thorough Knowledge of EOB denial/pend codes, HIPPS, HCPCS and DX codes in order to process claims within regulations. Escalating all Provider Claim issues and systemic errors to ensure positive rapport with our network Providers in accordance with PHCN Claims Policies and Procedures Perform other duties as assigned within the scope of responsibilities and requirements of the job Performs the essential functions of this job with or without reasonable accommodation. Knowledge of Medicaid EVV verification process required for accurate claims processing. Knowledge of PDGM reimbursement processing for Medicare claims. Knowledge of authorization process for accurate claims processing. Good communication skills and team player. Familiarity with EDI claims/ claims submission related to CMS requirements. Other duties as assigned.

Essential Qualifications

Years of Experience and Knowledge

2 ~ 4 years of direct experience minimum in Claims Adjudication and Clearinghouse submissions/rejections Basic Knowledge/understanding of Medicare/Medicaid claims processing and CMS regulations Detailed knowledge of medical coding; HIPPS, CPT and HCPCS codes Solid understanding of eligibility as well as claims paying for all lines of business 4~6 years’ work experience that provides a working knowledge of billing and delinquency procedures

Skills And Abilities

Beginner level Microsoft Office skills (PowerPoint, Word, Outlook) Beginner level Microsoft Excel skills Analytical, research, problem solving, and decision-making skills

Job-Type

Full time

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