Claims Analyst
Role Overview
The Claims Analyst is responsible for the analysis of claims data to identify any potential adjudication recommendations or recoupment opportunities on behalf of the Health Plan clients.
Requirements
Analyze surgical claims data from physicians and facilities for coding and charge accuracy.
Request medical records to support additional research and review of the claim.
Process and prepare medical records for clinical review by a nurse or physician.
Review implant configurations for coding and unit accuracy.
Manage all reviews and medical record requests within timeframes per service level agreements.
Utilize client specific medical and reimbursement policies to determine appropriateness of claim and whether the procedure is covered under the members health benefit plan.
Identify and aggregate provider information for providers who are consistently submitting inaccurate and or fraudulent claims to Health Plan.
Receive and respond to telephone calls and inquiries from providers and/or Health Plan clients.
Maintain documentation on status of activity and communication of outcome.
Respect and maintain HIPAA, PHI, and company confidentiality guidelines.
Other duties as directed.
Full Job Posting
Position Summary
The Claims Analyst is responsible for the analysis of claims data to identify any potential adjudication recommendations or recoupment opportunities on behalf of the Health Plan clients.
Requirements
Analyze surgical claims data from physicians and facilities for coding and charge accuracy.
Request medical records to support additional research and review of the claim.
Process and prepare medical records for clinical review by a nurse or physician.
Review implant configurations for coding and unit accuracy.
Manage all reviews and medical record requests within timeframes per service level agreements.
Utilize client specific medical and reimbursement policies to determine appropriateness of claim and whether the procedure is covered under the members health benefit plan.
Identify and aggregate provider information for providers who are consistently submitting inaccurate and or fraudulent claims to Health Plan.
Receive and respond to telephone calls and inquiries from providers and/or Health Plan clients.
Maintain documentation on status of activity and communication of outcome.
Respect and maintain HIPAA, PHI, and company confidentiality guidelines.
Other duties as directed.
Education, Experience and Licensure
High School Diploma or equivalent is required. Associate’s or Bachelor’s Degree in Healthcare or related field.
Minimum of 2 years’ experience in Customer Service, or applicable healthcare operations.
5+ years claim processing experience and demonstrated ability to handle multiple assignments competently, accurately, and efficiently.
Certification REQUIRED (One of the following):
Certified Outpatient Coding (COC), (aka CPC-H) by the American Academy of Professional Coders
Certified Professional Medical Auditor (CPMA), by the American Academy of Professional Coders
Certified Coding Specialist (CCS), or Certified Coding Associate (CCA) by the American Health Information Management Association (AHIMA) Licensure, Certification
Knowledge and Skills
- Certified Coding Expertise; Knowledge of medical coding concepts and the uses of ICD10, HCPCS/CPT, and DRG coding.
- Working knowledge of CMS rules, regulations, policies, and procedures.
- Intermediate proficiency in Microsoft Office Suite (Excel, Outlook, PowerPoint, Word).
- Excellent communication and customer service skills and analytical and problem-solving capabilities.
- Must be a highly organized, team player that is able to organize, prioritize and complete work in a timely manner despite many deadlines and competing priorities.
- Working knowledge of computers, or a demonstrated technical aptitude and an ability to quickly learn new systems.
- TurningPoint Healthcare Solutions is an Equal Opportunity Employer.
Requirements
- Certified Coding Expertise; Knowledge of medical coding concepts and the uses of ICD10, HCPCS/CPT, and DRG coding.
- Working knowledge of CMS rules, regulations, policies, and procedures.
- Intermediate proficiency in Microsoft Office Suite (Excel, Outlook, PowerPoint, Word).
- Excellent communication and customer service skills and analytical and problem-solving capabilities.
- Must be a highly organized, team player that is able to organize, prioritize and complete work in a timely manner despite many deadlines and competing priorities.
- Working knowledge of computers, or a demonstrated technical aptitude and an ability to quickly learn new systems.
- TurningPoint Healthcare Solutions is an Equal Opportunity Employer.
About TurningPoint Healthcare Solutions
Specialty condition management company helping health plans and providers manage complex musculoskeletal and cardiovascular care.
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