What are the responsibilities and job description for the Claims Analyst position at SOUTH FLORIDA COMMUNITY CARE NETWORK LLC?
Job Details
Description
POSITION SUMMARY:
This position is responsible for performing pre-payment audits and ensuring timely and accurate claim payments utilizing analytic reporting and coding software tools.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Facilitates pre-payment audit reporting and payment posting process to ensure accuracy of payments being made to providers and facilities.
- Review and process claim audit coding reports on a daily basis to ensure appropriate edits are applied in order to achieve the maximum financial outcomes.
- Creates claim adjustments, retro adjudications due to rate changes, and reprocessing projects identified during the internal audit process.
- Request and post claim payment refunds and recoup overpayments as necessary.
- Reviews all identified over/under payments to determine whether claims payment discrepancies are due to system configuration, training issues or erroneous claims processing.
Claims Analyst Job Description Page 1 of 3 7/25/2018
- Responsible for testing of benefit design, contracts, and all claims related system updates and upgrades.
- Responds to claims questions from all departments and assists with problems encountered on a daily basis.
- Responsible for first level claim appeals processing in accordance with contractual requirements.
- Applies accurate principles, policies, procedures and regulations, including: benefit interpretation, Coordination of Benefits (COB), deductibles, co-insurance and out of pocket maximums to the adjudication process.
- Regularly trains, assigns, coordinates, and reviews the work of staff.
- Advise Claims Management of any problems or inaccuracies as a result of daily operations.
- Processes claim corrections and COB updates via interdepartmental CRM process.
- Assists with projects and internal or external audits as needed.
- Identifies inappropriate or questionable claims and refers to Claims Leadership for review.
- Keep current on all plan benefits, contracts, and claims system upgrades.
- Processes professional claims, facility claims, ad hoc vendor payments and member reimbursement requests as needed.
- Update and create internal Standard Operating Procedures and provide related training to team members.
- Responsible for identifying efficiencies and recommending process improvements to increase auto-adjudication rates and reduce manual processes.
- Maintains courteous, helpful and professional behavior on the job and displays a willingness and ability to be responsive in a warm and caring manner to all customer groups.
SKILLS AND ABILITIES:
- Must maintain a good rapport and cooperative working relationship with internal and external customers.
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- Able to work independently with minimal supervision.
- Adhere to time and attendance policies.
- Ability to maintain composure under pressure.
- Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents.
- Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community.
- Ability to write speeches and articles for publication that conform to prescribed style and format.
- Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
- Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
PHYSICAL DEMANDS:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.
WORK ENVIRONMENT:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work
inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.
We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating and preserving a culture of diversity, equity and inclusion.
Qualifications
- High School or general education degree (GED); and five to seven years related claims experience and/or training. Associate degree preferred.
- Medical Coding Certification- CPC or equivalent preferred.
- Must have familiarity with ICD10-CM, HCPCS level II and III, CPT, revenue codes, and DRG coding on UB-04 and CMS 1500 claim types.
- Able to train staff through written, verbal and demonstration methods.
- The person in this role must possess a high level of expertise with medical claims processing/adjudication workflows, fee schedules, contract terms, coverage and reimbursement policies and claims processing standards.
