Claims Analyst

Under the direction of the Manager of Claims, the reviewer performs initial review of claims, including HCFA 1500 and UB 04 claims. Reviewer must meet or exceed production and quality standards and follow documented policies and procedures.

Required:

1. Ability to follow written directions and work independently.
2. Familiarity with medical terminology, CPT and ICD-9/ICD-10 coding is preferred.
3. Computer and typing experience is required.

Desired:

1. Experience in billing or physician office experience is preferred.. .
2. Previous claims payment experience.
3. Ability to understand medical terminology.

Responsibilities:

1. Performs initial review of all claim edits as directed. Completes or routes all reviews in accordance with time parameters established by The Health Plan.
2. Reviews each claim flag in sequence, totally completing one at a time in accordance with established criteria/payment guidelines.
3. Reports patterns of incorrect billing and utilization to the Medicare Claims Manager.
4. Advises Coordinators of items that are unclear or that are not addressed in the established criteria/payment guidelines.
5. Reviews claims from all areas as assigned on a daily basis with departmental standards for productivity, timeliness, confidentiality and accuracy of claims adjudication.
6. Responds to questions, telephone calls and documents regarding the company's payment and utilization review decisions.
7. Maintains quality ratings thresholds for 6 consecutive months.
8. Processes quantity thresholds of 17-20 claims per hour.
9. Participates in external and/or internal trainings as requested.
10. Consistently displays a positive attitude and acceptable attendance.
11. Maintains annual performance evaluations of commendable and distinguished.