Claims Analyst

Summary:

Responsible for validating disputes presented on Explanation of Benefits (EOB), entering denied claim into the DMT database, and escalating payment /variance trends to Management and generating appeals for denied or underpaid claims.

 

Essential Functions:

1. Validate denial reasons and ensures coding is accurate and reflects the denial reasons.  Coordinate with the Clinical Resource Center (CRC) for clinical consultations or account referrals when necessary
2. Generate an appeal based on the dispute reason and contract terms specific to the payor. This includes online reconsiderations.
3. Follow specific payer guidelines for appeals submission
4. Escalate exhausted appeal efforts for resolution
5. Work payer projects as directed
6. Research contract terms/interpretation and compile necessary supporting documentation for appeals, Terms & Conditions for Internet enabled Managed Care System (IMaCS) adjudication issues, and referral to refund unit on overpayments.      
7. Perform research and makes determination of corrective actions and takes appropriate steps to code the system and route account appropriately.
8. Escalate denial or payment variance trends to NIC leadership team for payor escalation.

• HS/Diploma GED equivalent
• 2 years minimum in a Hospital  or RCM environment performing billing / collections / disputes & claims research
• Payer Knowledge – MUST be strong in payer knowledge & being able to identify trends
• AR follow up Experience
• Intermediate understanding of Explanation of Benefits form (EOB).
• Understanding of UB-04 / 1500 forms 
• Medical terminology
• Intermediate Microsoft Office (Word, Excel) skills
  • Advanced business letter writing skills (Correct use of punctuation / grammar) 
• Must be able to multi-task and adapt to change

Advantages of this Opportunity:

• Competitive salary, negotiable based on relevant experience
• Benefits offered, Medical, Dental, and Vision
• Fun and positive work environment
• Monday-Friday must be available from 8:00AM to 5:00PM hour shift.