Medical Claims Analyst - Claims Processor REMOTE

Overview

We are currently hiring a REMOTE Claims Analyst
! If you are a knowledgeable, passionate, detail-oriented individual with healthcare billing experience and value being part of a team that makes a difference, you may be the right person for the position. Apply today!

Classification: NON-EXEMPT |
Status &

Schedule:

FULL-TIME, MONDAY – FRIDAY, 8AM – 5PM
Location: REMOTE
Work Location: OR, CA, AZ, TX, FL
Salary: $/ HOURLY
Department: Claims |
Reports to: CLAIMS MANAGER |
Supervision Exercised: NON-SUPERVISORY

This position is responsible for the review and analysis of medical claims for accuracy and completeness and the adjudication of claims using the appropriate contract benefits. This position also responds to incoming provider inquiries in a professional, timely manner.

• High school diploma or GED equivalent required
• Knowledge of facility and professional pricing methodologies like DRG, case rate, per diem, % of billed, fee schedules, etc. is required.
• Three years of experience with healthcare claims billing or adjudication experience preferred
• Experience with inpatient and outpatient facility billing (UB04/837I) preferred
• Coding and billing certification strongly preferred (CPC, CPB, COC, CIC, CCS, CCA)
• Will give preference to certified applicants or applicants who are currently obtaining certification.

• Understand Oregon Health Plan benefits, company policies, and Plexis Quantum Choice claims payment program
• Process institutional and professional claims, utilizing CMS pricer, Visium, Encoder Pro, and knowledge of payment methodologies (DRG, APC, ASC, SNF-RUG, etc)
• Answer inbound calls and respond to provider inquiries about claim status and adjudication
• Adjust claim payments when necessary
• Apply guidelines for surgical centers, CPT codes, HCPCS, REV codes, ICD-10, NCCI Edits, National Drug Code, and other code sets
• Analyze and adjudicate claims in line with Health Plan Contract and company policies
• Pay, pend, or deny claims based on eligibility, referral/prior authorization, COB, medical review, and claims policy
• Research and review claims that need additional data, coordinating with billing offices as required
• Deliver exceptional customer service, addressing plan coverage and payment inquiries
• Ensure timely response to inquiries, document interactions, and conduct necessary research
• Identify and correct errors, handle over payments, and issue refund requests
• Maintain comprehensive documentation of claim decisions via phone, email, fax, and courier
• Cross-train in various department functions to enhance efficiency
• Participate in quality and organizational process improvement activities and teams as requested
• Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
• Handle confidential information and materials appropriately and maintain a secure work area
• Perform other assigned duties

• Participate in quality and organizational process improvement activities when requested
• Support and contribute to effective safety, quality, and risk management efforts by adhering to established policies and procedures
• Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner
• Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization
• Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors
• Recognize new developments and remain current in care management and coordination best practice standards
• Advance personal knowledge base by pursuing continuing education to enhance professional competence
• Promote individual and organizational integrity by exhibiting ethical behavior
• Represent organization at meetings and conferences as applicable

• Comprehensive knowledge of medical claims, Oregon Health Plan eligibility data elements, and relevant coding systems and code sets (CPT, HCPCS,…