JOB SUMMARY

The Claims Adjustment Analyst performs extensive reviews on member or provider claim issues to calculate root cause research. Researches and investigates previously paid or denied claims to correctly apply benefit determination and pricing in accordance with claims processing guidelines.

ESSENTIAL FUNCTIONS OF THE ROLE

• Performs extensive reviews on member or provider claim issues to learn root cause research. Documents, tracks, resolves and reports findings. Provides professional assistance to other staff, members and providers by researching and resolving claims payment issues resulting from configuration or processing errors. Follows up with appropriate department to resolve front end issues.
• Participates in assessing written responses to highly sensitive provider appeals that result in an adjustment to previously processed claims. Provides an enhanced level of claims knowledge and assistance to the Customer Service team. Handles escalated caller issues from the Customer Service team. Properly responds to and follows up on any outstanding issues.
• Researches written inquiries, service forms and emails regarding previously paid or denied professional and facility claims effectively gathering documentation needed to process adjustments. Examines information including, but not limited to, authorizations, benefits or payments according to claims processing guidelines.
• Interprets and processes adjustments in accordance with claims processing guidelines. Identifies overpayments, records and sends letters requesting refunds.
• Works adjustment inventory from assigned queues and service forms to ensure all claims are processed within established turnaround time as directed by department policies and procedures. Consistently meets/exceeds productivity standards and accuracy standards for payment, procedural and financial.
• Handles separate provider issues through phone calls, service forms or correspondence for final resolution. Obtains information and responds to questions regarding third party liability, and acts as liaison to members and providers in accordance with established policies and procedures. Accurately documents phone log records for each customer inquiry. Adjusts claims payment and enters appropriate claim remarks or forwards requests to appropriate area for reprocessing or recoupment.
• Completes reports and special projects to ensure prompt adjustment or recovery of paid claims in accordance with turnaround time standards. Updates service excellence spreadsheet for tracking, trending and reporting service failure. Identifies and reviews problems, systematic or procedural, with management. Performs follow-up and takes all necessary actions required to resolve errors and findings assessed by the Quality Review Team.
• Protects data integrity and validity. Abides by patient confidentially (HIPAA) regulations and guidelines for accessing and disclosure of protected health information.

KEY SUCCESS FACTORS

• HMO/PPO experience is preferred. Previous Claims experience required.
• Medical terminology, CPT, HCPCS, ICD9, ICD10, and coding preferred.
• Ability to use good judgment and sense in evaluating and resolving difficult claims issues.
• Ability to work autonomously, with minimal supervision to meet internal and external customer satisfaction goals. Must be a sound recommendation maker.
• Responds positively to goal-setting and performance measurement. Easily adapts and responds effectively to shifts in priorities and unexpected events.
• Excellent verbal and written communication skills with attention to detail.
• Ability to comprehend and adhere to policies and procedures.
• Excellent diagnostic, problem solving skills and organizational skills.
• May be required to work in excess of regular scheduled hours.

BENEFITS

Our competitive benefits package includes the following

• Immediate eligibility for health and welfare benefits
• 401(k) savings plan with dollar-for-dollar match up to 5%
• Tuition Reimbursement
• PTO accrual beginning Day 1

Note: Benefits may vary based upon position type and/or level

QUALIFICATIONS

• EDUCATION - H.S. Diploma/GED Equivalent
• EXPERIENCE - 3 Years of Experience