Claims Analyst

The Claims Analyst is responsible for the completion of medical bill reviews. This position utilizes the system database to determine the reasonable cost of medical care within a specific geographic area and manually reviews for reasonableness, rarity, duration, application of proper fee schedule, accurate diagnosis and CPT coding, bundling/unbundling, drugs, supply coding, and duplicate billing. This position ensuresreviews are completed with highest quality and integrity and that all work is in full compliance with client contractual agreements, regulatory agency standards and/or federal and state mandates.

ESSENTIAL DUTIES AND RESPONSIBILITIES TO PERFORM THIS JOB SUCCESSFULLY INCLUDE, BUT ARE NOT LIMITED TO THE FOLLOWING:

• Receives client submissions and inputs client and examinee data in the system database.
• Sorts and verifies each claim contains all information required to conduct the review.
• Processes claims by correctly identifying the billing type (physician, surgery center, hospital, etc) and entering medical bills into the reviewing system, allowing automated adjudication to process.
• Reviews each claim and addresses all necessary modifications manually.
• Contacts client to resolve questions, inconsistencies, or missing data needed for review.
• Performs quality assurance on every case prior to completion.
• Ensures all medical records and reports are properly documented and saved in the appropriate location and available for audit at all times.
• Processes client invoicing in accordance with the client’s fee schedule.
• Handles and responds promptly to incoming calls, emails or faxes from clients requesting report status and/or information.
• Responsible for all client system set up including treatment parameters, audit parameters and continued file maintenance.
• Provide notification to the Supervisor of any provider appeals and follow directions as given to resolve the claim.
• Responsible to inform management of any issues, concerns, updates or changes needed to a client’s profile, report of sale and/or client identification numbers.
• Communicates any issues, errors, or questions concerning the medical review bill system with management and/or with the IT helpdesk.
• Ensures all practices are carried out in accordance with HIPPA compliance practices, state and federal safety standards and legal regulations.
• Promotes effective and efficient utilization of clinical resources and supplies.
• Perform other duties as assigned.

EDUCATION AND/OR EXPERIENCE

High school diploma or equivalent required. Minimum one year clerical experience; or equivalent combination of education and experience required. Experience in a medical office or insurance industry with knowledge and experience utilizing ICD9, CPT coding and Medical Terminology preferred.

QUALIFICATIONS

• Must have a full understanding of claim adjudication for First & Third Party, Med Pay, No-Fault, Group Health, Workers Compensation, hospital claims and PPO.
• Must have full understanding of the various types of medical billings and ability to identify which system database should be used.
• Must be able to cross reference different types of billings to ensure consistency in the review process.
• Must possess knowledge of standard fee schedule review, UC&R review, drug and supply charges, rarity, utilization review, CPT guidelines, ICD-9 coding, bundling/unbundling and duplicate billing.
• Must possess complete knowledge of general computer, fax, copier, scanner, and telephone
• Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
• Must have a full understanding of HIPPA regulations and compliance.
• Must be a qualified typist with a minimum of 35 W.P.M.
• Ability to follow instructions and respond to managements’ directions accurately.
• Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.
• Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.
• Must be able to work independently, prioritize work activities and use time efficiently.
• Must be able to maintain confidentiality.
• Must be able to demonstrate and promote a positive team -oriented environment.
• Must be able to stay focused and concentrate under normal or heavy distractions.
• Must be able to work well under pressure and or stressful conditions.
• Must possess the ability to manage change, delays, or unexpected events appropriately.
• Demonstrates reliability and abides by the company attendance policy.
• Must maintain a professional and clean appearance at all times consistent with company standards.