Claims Review Analyst

Summary of Position

• Support contract performance management of a large health system.
• Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on contractual and industry guidelines.
• Identify and analyze single issues and trends to determine root causes.
• Provide recommendations for solutions to minimize errors and delays in systems and/or processes.
• Monitor system output to ensure proper functioning.

• Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims review.
• Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is returned to the provider timely.
• Track issues and monitor trends to support their resolution.
• Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management.
• Improve quality, enhance workflow, and provide efficiencies within departments, identify opportunities for improvements; develop and present recommendations for changes.
• Conduct regular meetings with the assigned provider groups for status of AR files and recycles.
• Support departmental goals for cycle time by organizing and tracking claims for review.
• Monitor and provide timely responses for the designated provider group emails and AR files.
• Perform other related tasks as directed or required.

• Bachelor's degree; additional experience/specialized training may be considered in lieu of educational requirements required.
• 2 - 3 years' prior related work experience in professional/facility claims or benefits/billing environment required.
• Strong knowledge of claim processing policies and procedures required.
• Knowledge of medical terminology, ICD/CPT coding, per diem and DRG reimbursement and EDP testing procedures required.
• Proficiency with MS Office applications (word processing, database/spreadsheet, presentation) required.
• Ability to accurately interpret information from contractual and technical perspectives required.
• Must be conscientious and detail oriented; ability to recognize unusual patterns and troubleshoot for operational improvement and efficiencies required.
• Strong analytical and problem-solving skills required.
• Ability to effectively work on multiple projects/tasks with competing priority levels and deadlines required.
• Ability to effectively absorb and communicate information required.
• Strong interpersonal and teamwork skills required.