Claims Review Analyst

Role Overview

Join our team as a Claims Review Analyst supporting the contract performance management of a major health system. This role entails scrutinizing suspected underpayments and overpayments of claims from hospitals, ancillary services, and provider groups, ensuring adherence to contractual and industry standards.

Key Responsibilities

• Assess disputed claims to identify system configuration, claims processing, or contractual discrepancies to facilitate thorough claims review.
• Organize and maintain detailed documentation related to claims disputes, ensuring timely and accurate communication with providers.
• Monitor and track recurring and single-incident issues, analyzing trends and presenting root cause findings to management.
• Recommend process improvements aimed at enhancing quality, workflow, and operational efficiency.
• Lead regular meetings with assigned provider groups to update on accounts receivable files and recycling processes.
• Manage claims review cycle times and respond promptly to provider group inquiries through designated channels.
• Perform additional related duties as assigned to support departmental objectives.

Qualifications

• Bachelor's Degree is required; alternatively, significant experience or specialized training may substitute for formal education.
• Two to three years of relevant experience in professional or facility claims, benefits, or billing environments.
• In-depth understanding of claims processing policies and procedures.
• Familiarity with medical terminology, ICD/CPT coding, per diem and DRG reimbursement methodologies, and EDP testing procedures.
• Proficiency in MS Office suite, including word processing, spreadsheets, databases, and presentations.
• Strong capacity to interpret contractual and technical information accurately.
• Attention to detail with the ability to detect irregular patterns and contribute to operational enhancements.
• Demonstrated analytical and problem-solving capabilities.
• Ability to multitask effectively and handle competing priorities and deadlines.
• Excellent communication skills and a collaborative team-oriented mindset.