POSITION TITLE: Claims Analyst
DEPARTMENT: Operations - Claims
FLSA STATUS: Non - Exempt
REPORTS TO: Senior Manager, Claims
EVALUATION DATE: 9/ 2012
This position is accountable for accurate and timely adjudication of claims transactions utilizing edit queues, provider inquiries, refunds, as well as researching and analyzing to determine root causes to streamline the Claims Department’s processes. This position must keep current on claim processing procedures and produce a quality and timely work product.
ESSENTIAL DUTIES & RESPONSIBILITIES
Work claim issues from identification to resolution. This entails:
Identifying claims processing anomalies and offer solutions to address
Completing root cause analysis for claims that are not processed accurately
Identifying system or process deficiencies and offer suggestions for corrective actions
Participating and providing feedback on claims system configuration testing
Researching claim errors or inaccurate claim payments and identifying fixes
Represent the claims department as a subject matter expert and provide input into decisions, planning, etc.
Coordination of benefits/other health coverage
Overpayments (provider refunds) and reimbursement requests
The accurate and timely research and adjudication of claim recoveries and overpayments, including:
Keeping the Department’s claim inventory current through the processing of claims, conforming to established standards for quality and timeliness, to include the following processing expectations
Clear edit queues as assigned:
Make decisions regarding complex and non-routine claims processing
Utilize a variety of claims pricing tools for complex manual pricing of claims
Interpret complex provider contracts to determine claims payments
Process claims according to completeness and validity based on verification of eligibility and interpretation of program benefits, provider information and contracts
Determine the level of payment based on established criteria and defined provisions
Review claims for missing or incomplete information; requesting additional information needed to complete adjudication of claims
Review claims for necessity, limitations and exclusions based on claims policies and procedures
Document in claims notes to support payments or decisions
Ensure that the remit message provides the necessary explanation of payment for the provider
Reprocess /adjust claims when necessary.
Communication with Providers
Handle provider calls promptly and courteously regarding claims status, billing and payment issues, disputes, etc.
Provider Dispute Resolutions:
Responding to provider disputes in a timely and accurate manner.
Researching provider disputes to ensure appropriate resolutions.
Maintaining and updating the Provider Dispute Log.
Notifying manager of delay reasons that may affect timeliness of processing.
Work directly with provider groups and Provider Relations to resolve complex claims processing problems/issues
Manage smaller size projects within the department
OTHER DUTIES INCLUDE
Provide input to developing and maintaining current desk level procedures for claims processing.
Maintaining an up-to-date inventory and log of recoveries and documented efforts to collect reimbursement; identifying trends in recoveries that require management intervention.
Recognizing and documenting system issues, and working with manager and ITS to resolve
Keeping abreast of the changes in Medi-Cal regulations, program policies and current processing procedures.
Working with the Claims team to ensure consistent and accurate adjudication.
INDIVIDUAL CONTRIBUTOR EXPECTATIONS
Take the necessary steps to ensure he/she understands the SFHP mission and its overarching business goals and objectives.
Act with integrity, honesty and fairness, remaining mindful of the duty of trust SFHP has to it employees, and to its providers, employers and members.
Accept and adapt to changes in SFHP policy, practice, procedures quickly and positively and proactively supports his/her colleagues in adapting to changes in the workplace.
Contribute actively and effectively to team discussions, sharing his/her knowledge and expertise willingly and collaboratively.
Take steps to ensure he/she understands departmental performance competencies metrics. Strive daily to ensure his/her individual performance meets or exceed the performance competencies and metrics. Offer assistance to other members of the team as appropriate in order to help the team meet its overall metrics goals.
Focus on providing outstanding customer service daily to both external and internal customers.
Suggest process improvements that can streamline and improve SFHP customer service.
Model professional behavior/conduct that remains in concert with the SFHP culture and business values. Lead by example whether in group or individual meetings.
CORE COMPETENCIES / KNOWLEDGE & SKILL REQUIREMENTS
Detail oriented with problem-solving abilities.
Knowledge and application of English grammar including composition, editing and proofreading skills.
Strong organization, time management and project management skills and multi-tasking abilities.
Ability to handle detailed work, work with varying types of data and maintain confidentiality.
Ability to display a courteous, patient, and helpful attitude toward fellow employees and customers.
Basic understanding of SFHP policies and procedures.
EDUCATION, EXPERIENCE & TRAINING REQUIRED
A high school diploma with a college degree preferred.
A minimum of 5 years of prior medical claims processing experience.
Knowledge of managed care and Medi-Cal reimbursement.
Demonstrated depth of knowledge and experience in medical claims procedures, processes, governing rules and all aspects of claims adjudication including solid knowledge of claims coding and medical terminology.
Solid understanding of standard claims processing systems and claims data analysis.
QNXT application (V. 4.81 or later) experience preferred.
Above average interpersonal, written and verbal communication skills.
COMMUNICATION & INTERPERSONAL SKILLS
Must be able to understand complex written and oral instructions:
Ability to clearly present written information and findings
Ability to clearly communicate information
Ability to interact well with co-workers and outside contacts
Employees and other department staff
External (if applicable):
Providers, vendors, other health plans
ESSENTIAL FUNCTIONS—PHYSICAL POSITION REQUIREMENTS; MACHINES AND/OR EQUIPMENT USED
Must be PC literate; MS Office skills (Word, Excel, PowerPoint).
Regularly required to operate standard office equipment (personal computer, photocopy machine, fax machine, etc.)
Ability to work on a computer up to 7 hours a day.
Regularly required to sit for long periods of time, and occasionally stand and walk.
Regularly required to use hands to operate computer and other office equipment.
Close vision required for computer usage.
Occasionally required to stoop, kneel, climb and lift up to 25 pounds.
Standard office environment without unpleasant or hazardous conditions. Work entails typical physical demands involved in office work.
NOTE: This description is not intended to be construed as an exhaustive list of duties, responsibilities or requirements for the position. This position may change or assume additional duties at any time. The employee may be requested to perform different or additional duties as assigned
San Francisco Health Plan - 23 months ago