Claims analyst

Job Title: Claims analyst

Location: Omaha NE 68154

Duration: 12 months

Job Description:

Family Summary/Mission

Achieve superior claim and member service performance through an integrated process of operational, quality, medical cost, and resource management meeting and/or exceeding member, plan sponsor, and provider expectations.

Position Summary/Mission

Reviews and adjudicates routine claims in accordance with claim processing guidelines.

Fundamental Components & Physical Requirements include but are not limited to

(* denotes essential functions)

• Analyzes and approves routine claims that cannot be auto adjudicated. (*)

• Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process. (*)

• Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues.

• Routes and triages complex claims to Senior Claim Benefits Specialist. (*)

• Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements. (*)

• May facilitate training when considered topic subject matter expert. (*)

• In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic Correspondence Handling System-system used to process correspondence that is scanned in the system by a vendor). (*)

• Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., utilizes Claim Check, reasonable and customary data, and other post-containment tools). (*)

Performance Measures

Background/Experience Desired

• Experience in a production environment.

• Claim processing experience.