Senior Claims Analyst (Medical Claims)

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Job SummaryThis position includes a variety of claim administrative and technical tasks that support a Claim Unit and/or vendor staff, as well as the Claims Team and serves as a liaison for any internal departments.

In addition to these tasks, the Senior Claims Analyst is responsible for all of the same tasks as a Claim Analyst including the accurate adjudication and processing of medical, dental, vision, or other related claims, including related correspondence and/or electronic inquiries for assigned groups. All claims and inquiries are handled according to the established plan documents, claim processing guidelines, and established total turnaround times. Also advise team members regarding claim processing procedures.

This role is based remotely, however candidates must live in one the following states: IL, MT, IN, IA, KS, MO, NC, NM, OK, PA, TX or WI

Job Description:

• Resolve client, employee/member, or provider issues regarding escalated or complex claims.
• Review and release over-authority claims up to limit specified by corporate policy.
• Handle claim referrals, including pre-determinations, using internal and external resources as needed. Advice Claim Analysts and/or vendor regarding claim processing.
• Handle network referrals as well as PPO repricing disputes.
• Review, analyze and interpret claim forms and related documents.
• Determine benefit coverage based on clinical edits, plan documents/booklets, benefit reference documents, Claim Reference Manuals and claims-related memoranda, and reports.
• Appropriately investigate, pend and refer claims based on claim procedures and guidelines.
• Accurately handle correspondence, claims, and referrals in the established timeframes and/or performance guarantees.
• Support the Claims reinsurance team, in the research and resolution of claims as assigned
• Handle complex or technical claim adjudication using internal and external resources as needed, e.g. transplants, experimental & investigational, chemotherapy, etc.
• Research and respond to vendor reconciliation requests.
• Mentor and assist with onboarding new Analysts, including the oversight of work
• Support the management, monitoring, and tracking of performance in collaboration with the Supervisor.
• Provide mentoring and coaching
• Assist Supervisor in documenting processes for analysts
• Other duties as needed/assigned

Required Job Qualifications:

• High School diploma or GED equivalent
• 3 years prior medical claim processing experience
• Ability to work in a fast-paced, customer centric & production driven environment
• …