CLAIMS ANALYST

As a Medical Claims Analyst you’ll be responsible for determining eligibility of claims under major medical and self-insured plans, investigating charges, explaining payment or denials to claimants, and more.

Key responsibilities may include:

• Communicates internally & externally with clients, participants, brokers, agents, & more
• Analyzes claims to determine eligibility, medical facts, contract coverage & limitations
• Determines when to pay or deny claims, or request additional information
• Calculates payment of benefits in accordance with coverage information, contract language or plan document & medical documentation
• Screens all charges for reasonableness of costs & medical necessity
• Investigates excess or questionable charges by letter or telephone
• Determines possibility of coordination of benefits (COB) on each claim & calculates benefits accordingly
• Coordinates with member advocates to contact providers, members, and others in regard to claims, additional information, eligibility, and additional issues affecting claims adjudication
• Participates in continuous process improvement efforts, training junior team members, or offering insight on workflow enhancements.
• Provides insight or feedback on complex claim scenarios, escalations, or appeals requiring advanced plan interpretation.
• Additional responsibilities as assigned based on client and business needs

• High school diploma or equivalent
• Minimum of 3 years of direct experience processing or reviewing medical claims, preferably in a TPA, insurance carrier, or healthcare setting
• Experience & education may be substituted when equivalent, but direct experience is strongly preferred for this role
• Knowledge of CPT, HCPCS, IC10 coding
• Knowledge of claims processing & the Eldorado system (preferred)
• Skilled in customer service, with strong communication skills (interpersonal & written)
• Good at problem solving and analyzing information
• Comfortable with software and technology and willing to learn new systems
• Able to adapt to a constantly changing environment & multitask
• Able to accurately compile data, perform detailed work & maintain confidential information
• Able to meet deadlines
• Able to maintain attendance & present a professional appearance & demeanor
• Able to work well with others

• High school diploma or equivalent
• Minimum of 3 years of direct experience processing or reviewing medical claims, preferably in a TPA, insurance carrier, or healthcare setting
• Experience & education may be substituted when equivalent, but direct experience is strongly preferred for this role
• Knowledge of CPT, HCPCS, IC10 coding
• Knowledge of claims processing & the Eldorado system (preferred)
• Skilled in customer service, with strong communication skills (interpersonal & written)
• Good at problem solving and analyzing information
• Comfortable with software and technology and willing to learn new systems
• Able to adapt to a constantly changing environment & multitask
• Able to accurately compile data, perform detailed work & maintain confidential information
• Able to meet deadlines
• Able to maintain attendance & present a professional appearance & demeanor
• Able to work well with others