Senior Claims Analyst

Summary

Join our team as a Senior Claims Analyst! You will be responsible for reviewing and analyzing healthcare claims, ensuring accuracy and compliance with company policies and regulations. Your analytical skills will be crucial in identifying and resolving claim discrepancies. You will collaborate with providers, patients, and insurance companies to address claim issues and maintain detailed records. This role requires strong knowledge of healthcare claim processing, medical terminology, and claim coding. The ideal candidate will have at least 5 years of experience in healthcare claims processing and a degree in a related field.

Requirements

• Minimum of 5 years of experience in healthcare claims processing or a similar role
• Strong knowledge of institutional claims processing, including inpatient and outpatient claims
• Experience in repricing and pricing claims based on provider contracts, reimbursement methodologies, and regulatory guidelines
• Proficiency in interpreting revenue codes (rev codes), Ambulatory Payment Classification (APC) pricing, and Diagnosis-Related Groups (DRGs) for proper claim adjudication
• Expertise in inpatient and outpatient claims review, ensuring compliance with payer policies and contractual agreements
• Ability to analyze claims data, identify discrepancies, and ensure accurate payment processing and reimbursement
• Familiarity with medical terminology, claim coding (ICD, CPT, HCPCS), and insurance billing practices
• Strong analytical and problem-solving skills
• Excellent attention to detail and accuracy
• Proficiency in using claims management software and Microsoft Office Suite
• Effective communication and interpersonal skills
• Ability to work independently and as part of a team

Responsibilities

• Review and analyze healthcare claims for accuracy, completeness, and eligibility
• Ensure claims are processed in accordance with company policies, procedures, provider contracts and regulatory requirements
• Verify patient and provider information and validate claim codes (ICD, CPT, HCPCS)
• Identify discrepancies and inconsistencies in claims and take appropriate corrective actions
• Communicate with healthcare providers, patients, and insurance companies to resolve claim issues
• Investigate and resolve denied or rejected claims
• Accurately enter claim information into the claims management system
• Maintain detailed and organized records of claims and related correspondence
• Prepare and generate reports on claim status, trends, and performance metrics
• Stay updated on industry regulations and guidelines related to healthcare claims processing
• Ensure compliance with HIPAA and other regulatory standards
• Participate in quality assurance reviews to identify areas for improvement and implement best practices
• Work closely with the Claims Manager, Director of Provider Operations, and other team members to improve claim processing workflows
• Provide training and support to new team members as needed
• Communicate effectively with internal and external stakeholders to facilitate smooth claims processing

Preferred Qualifications

Associate’s or Bachelor’s degree in Healthcare Administration, Business, or a related field