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Claims Processing Analyst

2 months ago

Bakersfield, California, United States Innovative Integrative Health Full time
Job Type

Full-time

Overview

Are you passionate about contributing to an organization dedicated to empowering diverse and underserved senior communities to maintain their independence at home?


Innovative Integrative Health is committed to delivering comprehensive health and social services that effectively manage chronic conditions and minimize the risk of premature institutionalization.

Our team is at the forefront of the 'aging in place' movement, proudly serving seniors and their families across various regions.


Position Summary:
The Claims Processing Analyst plays a crucial role in overseeing liability claims, ensuring the accuracy and completeness of submitted claims. This position involves reviewing contract details and policies to identify eligible charges for reimbursement, thereby supporting the organization's financial health.

Key Responsibilities

  • Examine claims and appeals for precision, thoroughness, and eligibility.
  • Conduct analyses and audits of claims to ensure compliance and propose solutions for any discrepancies.
  • Generate financial estimates weekly utilizing Microsoft Excel.
  • Provide feedback and rationale for denied claims to providers as necessary.
  • Assist providers in the claims submission process and verify participant eligibility.
  • Perform basic contract reviews to validate payment rates.
  • Collaborate with various departments within the organization.
  • Request monthly inventory updates from the Third Party Administrator (TPA).
  • Follow up on claims pending closure.
  • Ensure claims are linked to pre-authorizations from the Interdisciplinary Team (IDT) and/or Primary Care Provider.

  • Coordinate benefits to ascertain the impact of primary and secondary insurance on claims.
  • Analyze claims loss and expense reserves, reconciling claims reports with authorization documentation.
  • Process new claims and distribute them to the TPA.
  • Report claims-related issues to the IDT, Primary Care Providers, and senior management as appropriate.
  • Support the Claims Supervisor in identifying potential exposures and report pending claims and litigation that may affect corporate objectives.

  • Act as a liaison between the TPA, provider network, insurance companies, and other stakeholders as needed.

  • Verify claim pricing against contracted rates and Medicare/Medicaid fee schedules.
  • Exhibit workplace behaviors that reflect the organization's core values of integrity, respect, and patient-centered care.

  • Participate in staff meetings, training sessions, projects, and committees as assigned.
  • Adhere to organizational practices, procedures, and policies, including attendance and break times.
  • Accept assigned responsibilities cooperatively and perform additional related duties as required.
  • Be adaptable regarding work hours.
  • May require the use of a personal vehicle.

Qualifications

  • High School Diploma with a minimum of two (2) years of relevant experience required; Bachelor's degree preferred.
  • 2+ years of professional experience in claims processing and analysis is strongly preferred.
  • Proficient in Microsoft Office Suite (Word, Excel, Access, PowerPoint, Publisher, and Outlook); candidates will undergo a Microsoft Office proficiency assessment.
  • Strong organizational skills with the ability to manage multiple tasks effectively while maintaining attention to detail.
  • Excellent written and verbal communication skills.
  • Ability to quickly grasp departmental policies, procedures, and objectives.
  • Detail-oriented with a strong focus on accuracy.

Core Values

  • Respect in all interactions.
  • Integrity and honesty in every endeavor.
  • Patient-centered care aligned with participant values and preferences.
  • Encouragement that empowers individuals to excel.
  • Quality care that is efficient and innovative.

Salary

$22.50