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Healthcare Claims Analyst

2 months ago

Phoenix, Arizona, United States Triwest Healthcare Full time
Veterans, Reservists, Guardsmen and military family members are encouraged to apply

We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only)

Job Overview

As a Medical Claims Reviewer, you will be responsible for conducting thorough evaluations of behavioral health and medical/surgical claims for both inpatient and outpatient services. Your primary goal will be to determine medical necessity, assess benefit coverage, and evaluate the appropriateness of care quality and length of stay or care plans. Utilizing your clinical, coding, and processing expertise, you will review and process claims effectively. You will compile and analyze clinical information necessary for case preparation, ensuring compliance with authorized program benefits. Additionally, you will provide essential clinical and coding-related insights to various stakeholders, including medical directors, providers, peer reviewers, and claims administration teams.

Qualifications & Experience

Required:

• Active, unrestricted RN license
• U.S. Citizenship
• Ability to pass a favorable Department of Defense (DoD) background investigation
• Minimum of 2 years of clinical experience in direct patient care (medical or behavioral health)
• At least 2 years of Utilization Management experience with commercially developed criteria or medical claims processing

Preferred:

• Over 2 years of experience in Managed Care
• More than 1 year of experience with TriWest or TRICARE
• Familiarity with Current Procedural Terminology

Key Responsibilities

• Perform medical claims evaluations using established clinical criteria and claims processing guidelines to assess medical necessity and appropriateness of care.
• Prepare cases for review by medical directors as needed.
• Ensure all necessary data is included with program invoices.
• Analyze claim data to identify process improvements in claims processing.
• Maintain compliance with contractual timelines for resolving medical claims.
• Communicate effectively with management and colleagues.
• Consistently meet production and quality metrics for medical claims processing.
• Identify and report potential quality or fraud issues as necessary.
• Provide clinical and coding support for various projects and inquiries.
• Carry out additional duties as assigned.
• Ensure regular and reliable attendance.

Competencies

Coaching / Training / Mentoring: Provide constructive feedback to foster desired business outcomes.

Commitment to Task: Adhere to established policies and procedures while demonstrating high motivation.

Communication / People Skills: Influence and persuade others effectively while adapting to different communication styles.

Computer Literacy: Proficient in a multi-system Microsoft environment, including Word, Outlook, and relevant department software applications.

Coping / Flexibility: Demonstrate resilience in adapting to various situations while maintaining focus.

High Intensity Environment: Ability to thrive in a fast-paced environment with multiple concurrent activities.

Organizational Skills: Effectively organize tasks and priorities within time constraints.

Team-Building / Team Player: Foster positive influence and build group commitment.

Technical Skills: Comprehensive knowledge of policies, Managed Care concepts, and medical terminology. Proficient with claims and coding tools.

Working Conditions

Working Conditions:

• Availability to work any shift
• Ability to work independently from home
• Extensive computer work with prolonged sitting

Company Overview

Taking Care of Our Nation's Heroes.

It's Who We Are. It's What We Do.

At TriWest Healthcare Alliance, we are dedicated to connecting America's heroes with essential health care services. Since 1996, we have been committed to this vital mission.

Benefits

We offer a comprehensive compensation and benefits package, including:
  • Medical, Dental, and Vision Coverage
  • Generous paid time off
  • 401(k) Retirement Savings Plan (with matching)
  • Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
  • Tuition reimbursement
  • Paid volunteer time

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal opportunity employer, committed to fostering an inclusive work environment that values diversity at every level.