Claims Review Analyst

Payrate: $17.00 - $19.79/hr

Summary:
Responsible for triaging, researching and resolving clinical editing review request inquiries for all current and future Clinical Editing programs for all regions. Creatively researches and resolves processing issues through working with multiple sources, including external vendors, as needed.
 
Responsibilities:

• Coordinates inquiries by obtaining information from appropriate Medical Directors at in-plan IPAs, at Health Plan, Medical Claims Review nurses, internal staff and external customers as needed. Ensures turnaround times are met (as applicable)
• Assigns tracks and resolves specific clinical editing review inquiries. Develops and maintains logs as assigned. Maintains and updates clinical editing dispute review database for reporting and metrics
• Composes and (e-)mails communication for approved/denied inquiries and/or information/problem-solving requests. Communicates review results to providers
• Monitors and reports timelines for inquiry review, adjudication and response
• Enters claim information in claims remarks screen, indicating claim is currently under inquiry or appeal
• Contacts provider offices as needed to obtain correct claim/ordering information
• Constructs information for claim adjustments and forwards to Claim Research Unit
• Develops and prepares metrics to monitor department inquiries and functions on a weekly basis. Reviews logs, metrics and research issues with supervising staff
• Troubleshoots and identifies trends and recommends process gliches/improvements
• Represents the Clinical Editing Team as needed at other project teams that directly or indirectly impact coding requirements, claims processing or provider reimbursement
• Provides support for Correspondence, Claims and Provider Service units related to appeals
• Supports other member and provider appeals functions, as needed
• Supports other ClaimCheck appeal functions, as needed

 
Minimum Resource Qualifications:

• Bachelor’s degree in relevant field with a minimum of three years’ experience with claims operations or customer service. In the absence of a bachelor’s degree, significant work experience (minimum of five years) with coding, claims system operations and clinical editing tools may be substituted
• Certified Professional Coder (CPC) desired. Enrollment in CPC class within one year of hire required
• Experience/proficiency with spreadsheet, database, word processing, and coding software products required
• Excellent problem-solving ability and skill in communicating complex ideas
• Experience in health systems operations including an understanding of reimbursement methodologies and coding conventions for governmental and commercial products (e.g. Medicare, Medicaid, DRG, APC, RBRVS, CPT, HCPC, ICD9, etc)
• Understanding of the functionality and use of coding software products (e.g. ClaimCheck, Correct Coding Initiative (CCI))
• Understanding and extensive experience with claims processing systems (preferably CAPS/UWIN, LRSP, TOPPS, and FACETS), claims flow and adjudication process, system edits and display screens
• Strong communications skills including ability to present information
• Ability to follow-through with tasks independently
• Requires attention to detail and a customer-oriented attitude

 
Pay Transparency: The typical base pay for this role across the U.S. is: $17.00 - $19.79/hr. Non-exempt positions are eligible for overtime at a rate of 1.5 times the base hourly rate for all hours worked in excess of 40 in a work week, or as required by state or local law. Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education and experience. Full-time employees are eligible to select from different benefits packages. Packages may include medical, dental, and vision benefits, health savings accounts with qualified medical plan enrollment, 10 paid days off, 3 days paid bereavement leave, 401(k) plan participation with employer match, life and disability insurance, commuter benefits, dependent care flexible spending account, accident insurance, critical illness insurance, hospital indemnity insurance, accommodations and reimbursement for work travel, and discretionary performance or recognition bonus. Sick leave and mobile phone reimbursement provided based on state or local law. 

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