Job Details

Claims Research Analyst

Provides analyst support for claims research activities including reviewing and researching claims to ensure regulatory requirements are appropriately applied, identifying root-cause of processing errors through research and analysis, coordinating and engaging with appropriate departments, developing and tracking remediation plans, and monitoring claims reprocessing through resolution.

Essential Job Duties:

• Serves as claims subject matter expert - using analytical skills to conduct research and analysis to address issues, requests, and support high-priority claims inquiries and projects.
• Interprets and presents in-depth analysis of claims research findings and results to leadership and respective operations teams.
• Manages and leads major claims projects of considerable complexity and volume that may be initiated internally, or through provider inquiries/complaints, or legal requests.
• Assists with reducing rework by identifying and remediating claims processing issues.
• Locates and interprets claims-related regulatory and contractual requirements.
• Tailors existing reports and/or available data to meet the needs of claims projects.
• Evaluates claims using standard principles and applicable state-specific regulations to identify claims processing errors.
• Applies claims processing and technical knowledge to appropriately define a path for short/long-term systematic or operational fixes.
• Seeks to improve overall claims performance, and ensure claims are processed accurately and timely.
• Identifies claims requiring reprocessing or readjudication in a timely manner to ensure compliance.
• Works collaboratively with internal/external stakeholders to define claims requirements.
• Recommends updates to claims standard operating procedures (SOPs) and job aids to increase the quality and efficiency of claims processing.
• Fields claims questions from the operations team.
• Interprets, communicates, and presents, clear in-depth analysis of claims research results, root-cause analysis, remediation plans and fixes, overall progress, and status of impacted claims.
• Appropriately conveys claims-related information and tailors communication based on targeted audiences.
• Provides sufficient claims information to internal operations teams that communicate externally with providers and/or members.
• Collaborates with other functional teams on claims-related projects, and completes tasks within designated/accelerated timelines to minimize provider/member impacts and maintain compliance.
• Supports claims department initiatives to improve overall claims function efficiency.

Required Qualifications:

• At least 3 years of medical claims processing experience, or equivalent combination of relevant education and experience.
• Medical claims processing experience across multiple states, markets, and claim types.
• Knowledge of claims processing related to inpatient/outpatient facilities contracted with Medicare, Medicaid, and Marketplace government-sponsored programs.
• Data research and analysis skills.
• Organizational skills and attention to detail.
• Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.
• Ability to work cross-collaboratively in a highly matrixed organization.
• Customer service skills.
• Effective verbal and written communication skills.
• Microsoft Office suite (including Excel), and applicable software programs proficiency.

Preferred Qualifications:

• Health care claims analysis experience.
• Project management experience.

Pay Range: $19.84 - $46.42 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.