Medical Claims Analyst

JOB LOCATION: Clive Iowa (office-based) Hybrid or Remote

This position will be office-based during the required training which may last up to 6 months. Once training is complete the position may become hybrid or 100% remote-based subject to company remote-work policies. Working permanently on a remote or hybrid schedule is not a guarantee for this position.

POSITION SUMMARY: Under general supervision the Claims Analyst adjudicates claims in accordance with procedures and operations of group benefit plans. The Claims Analyst processes entry to mid-level complex claims accurately and pays health claims for medical prescription dental vision and partially self-funded benefit plans.

DUTIES AND RESPONSIBILITIES:

• Process timely and accurately claims in accordance with the group plan self-funded benefit specifications for all healthcare benefits.
• Process timely and accurately claims in accordance with the Facility and Provider Network and Pharmacy Benefit Manager requirements.
• Ability to monitor correctly apply and appropriately use modifiers as defined in the Current Procedural Terminology (CPT) reference book to ensure accurate benefit application.
• Must have a working knowledge of ICD10 Codes CPT Codes HCPC Codes and ADA Codes.
• Ability to recognize and accurately process claims for multiple services (i.e. surgeries anesthesia hospital inpatient/outpatient post-operative visits physical therapy office visits with or without lab or Xray services etc.)
• Ability to recognize and appropriately process claims submitted for services rendered using Benefit Categories as defined by the TRISTAR claims processing system to ensure accurate payment.
• Process accurately out-of-network (OON) or referenced based pricing (RBP) claims as applicable.
• Understand Coordination of Benefits rules and be able to apply coordinated benefits in the claims process.
• Ability to identify claims that require additional information and create system letters for other Insurance Accident inquiries and Pre-Determinations.
• Process responses to requests for additional information and take appropriate steps to facilitate the completion of claim processing and escalation ( i.e. coordination of benefits identification of possible subrogation claims).
• Work collaboratively with the Director of Operations and with team members in the departments of: Claims Member and Provider Services Eligibility and Enrollment Auditing and Cafeteria Plan (Section 125) administration as applicable to ensure accurate claims processing.
• When working a hybrid or 100% remote-based schedule must attend required company or division training meetings company sponsored activities/events job related and required business travel as applicable.
• Ensure when working a hybrid or 100% remote-based schedule that all communication and system resources such as instant messaging (Teams Chat) email Teams Meetings or other available resources or forms of communication are frequently used to stay in touch with the team supervisors and others within the organization.
• Timely report to the supervisor any system downtimes or interruptions whether working remotely hybrid or in the office.
• Obtain and maintain in good standing individual Claim Analyst licenses as required by the client insured program service agreement or state regulators.
• Regular attendance in accordance with hours of operation are essential functions of the job.
• Perform other duties as assigned.

EQUIPMENT OPERATED/USED: Computer 10-key printer copier fax machine and other office equipment.

SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attire required when working in the office and when conducting business with internal/external personnel remotely or on a hybrid schedule.

QUALIFICATIONS REQUIRED:

Education/Experience:

High school diploma or GED and two (2) years of experience working with health claims or member and provider services in the healthcare industry or similar.

Knowledge Skills and Abilities:

• Highly detail oriented exhibit excellent problem-solving skills and able to consistently perform at minimum or higher production.
• Extremely dependable and reliable; able to adapt to changes.
• Must have a positive attitude towards work and co-workers.
• Excellent communication skills both verbal and written are necessary.
• Ability to work independently and in a team environment.
• Must understand and comply with applicable HIPAA Privacy and Security policies regulations and laws.

• Ability to work collaboratively with various departments and teams.
• Ability to maintain composure under stressful conditions.
• Ability to communicate in English clearly and concisely both orally and in writing
• Possess an extensive working knowledge of medical terminology and medical procedures.
• Understand the importance of practicing good ergonomics in the workplace.