Health Plan Claims Analyst II-Selikoff Centers for Occupational Health

The Health Plan Claims Analyst II is responsible for multiple components of specific health plan operations. The Health Plan Claims Analyst II provides administrative operational and programmatic support services within an assigned area/department. This position requires strong problem solving skills analytical and organizational abilities. The position will also include quality assurance activities as well as making recommendation for process changes based on the outcome of these activities. The position will require coordination of workflow across multiple entities including payors providers and program leadership and therefore also requires effective communication.

• Trains and orients new staff on program policies and procedures.
• Conducts quality assurance for the team and proposes areas for process and quality improvement.
• Guides a wide range of network providers on the enrollment process for related Health Plan which includes providing education on health plan rules and claims processing process
• Conducts presentations on specific Health Program rules authorization process documentation requirements and clinical center review process to various stakeholders including providers and clinical center personnel
• Reviews requested medical documentation from program sponsor and presents required information to medical review team along with applicable guidelines supports medical review team with administrative review
• Reviews claims information for quality assurance purposes makes recommendations for process improvement or changes in documentation or workflow.
• Escalates ongoing payment challenges with program leadership and program sponsor; may present solutions to leadership and sponsor as well
• Reviews and approves claims for patients. Appropriately documents claim decisions (e-Claims portal) and reviews approval and denial patterns
• Maintains a working knowledge of Health Programs coverage and payment guidelines monitors changes in coverage and notifies program leadership of changes
• Identifies communicates and provides possible solutions on billing issues and patterns to program leadership.
• Maintains liaison with staff in other departments to coordinate program activities and training; to accomplish program objectives; and to ensure cooperative efforts are enhanced and available resources are utilized. Ensure that changes to the health p
• Recommends new ideas and concepts for program themes materials and resources to supplement expand or replace existing program components. Works with program leadership to develop the content of these materials
• Other duties assigned as needed.

• Bachelors Degree preferred or Associates Degree with 5 years of relevant experience
• 5 years experience in medical billing or health claims with experience in EPIC billing systems in a health care or insurance environment and familiarity with ICD/CPT coding.