SeniorClaims Examiner and Benefit Configuration Analyst
Under the supervision of the Claims Manager, the Senior Claims Examiner and Benefit Configuration Analyst is responsible for analyzing and processing claims and meeting defined quality and productivity standards.
As s benefit configuration analyst you would support cross-functional teams during implementations and build and manage benefit plans on various platforms to ensure a high quality product. This role will also be responsible for supporting the Plan Operations team with core benefits operations functions while building and maintaining accurate benefit configuration.
Desired Skills and Experience
- Work with clients, identifying and understanding benefit plan requirements. Build and maintain benefit plans for client groups.
- Aid in the organization of benefit configuration and structure for the accounts assigned by monitoring plan data integrity.
- Assist in determining process improvement efforts
- Maintain prior authorizations and step therapy rules.
- Collaborate with member support and customer success teams to review and resolve inquiries related to benefits timely to improve member experience.
- Provide troubleshooting support for our claims adjudication process.
- Support new client implementations conduct go-live testing, perform post go-live auditing and support to ensure plans are configured to confirm accuracy.
- Evaluates claims for completeness and validity to determine payment/denial according to provider contracts, authorizations, and Medicare processing guidelines
- Processes various Medicare and Medicaid claim types, including Professional, Facility and Dental claims
- Accurately analyzes and interprets provider contracts
- Researches claims and makes appropriate adjustments
- Assists with system configuration and testing for new clients
- Assists with testing of new processes, and provides feedback
- Reviews and tests fee schedules
- Reviews and approves batch close reports for examiners
- Analyzes and authorizes high dollar claims
- Determines appropriate payment for claims submitted for reconsideration (payment appeals)
Behavioral Skills
- Assists with training new or existing staff, as requested
- Responds to clients inquiries related to claims processing
- Communicates clearly and concisely, with sensitivity to the needs of others
- Execution-focused ethos – solutions oriented problem solver and efficiency driven.
- Flexible, dependable, adaptable and able to respond under pressure of fast paced technology company.
- Maintains courteous, helpful and professional behavior on the job; displays a willingness and ability to be responsive in a warm and caring manner to all customer groups; consistently cooperates and supports organization in problem solving issues; ensures customer satisfaction by understanding and applying the Customer Service Policy, Procedure and Standards; will support the success of the entire team; establishes and maintains effective working relationships with co-workers
- Follows all Policies and Procedures and HIPAA regulations
- Maintains a safe working environment