Health Plan Claims Analyst

Overview:

The Health Plan Claims Adjudicator processes both professional and institutional health plan claims utilizing the Health Plan's claim systems and policies and procedures to confirm eligibility and accurate processing.

Responsibilities:

ESSENTIAL FUNCTIONS:

• Review, evaluate, and process health plan claims received electronically and via mail.
• Assess eligibility and benefits prior to claims payment process to confirm if a claim is eligible for payment or should be denied due to discrepancies or errors.
• Make recommendations for resolutions of all health plan claims.
• Examine and analyze each claim to prevent fraud and coordinate with Compliance, Claims Auditor and Claims Manager as needed.
• Study and compare reports of similar claims to determine the extent of insurance coverage and evaluate completeness and validity of the claim.
• Determine settlement according to organization practices and procedures.
• Ensure compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations.
• Stay abreast of Claims System software updates.
• Collaborate with the Claims Management Team or other Health Plan Teams to ensure adjudication accuracy when needed.
• May perform other duties as assigned.

KNOWLEDGE/SKILLS/ABILITIES:

• Thorough understanding of health plan claims processing principles, coding systems, and reimbursement methods.
• Proficiency in utilizing claims processing software and systems (VBA preferrable).
• Knowledge of health plan regulatory compliance requirements, including HIPAA, CMS guidelines, and Texas regulations.
• Analytical mindset with the ability to interpret complex data, identify trends, and recommended data driven solutions.
• Strong attention to detail.
• Ability to think analytically and problem-solve.
• Ability to effectively prioritize tasks and assignments.
• Excellent written and verbal communication skills.
• Working knowledge of medical terminology and abbreviations.

Qualifications:

EDUCATION:

• High School Diploma required.
• Bachelor's Degree in Healthcare Administration, Business Management, or related field preferred.

EXPERIENCE:

• 3 years experience in Health Plan claims adjudication, preferably with an HMO or managed care environment required.