Claims Review Analyst
Company: Emblem Health
Posted on: May 3, 2021
Support contract performance management of a large health
system. Review and analyze suspected underpaid and overpaid claims
from hospital, ancillary, and provider groups based on contractual
and industry guidelines. Identify and analyze single issues and
trends to determine root causes. Provide recommendations for
solutions to minimize errors and delays in systems and/or
processes. Monitor system output to ensure proper functioning.
- Evaluate disputed claims for system configuration, claims
processing, and/or contractual issues to facilitate claims
- Maintain and organize detailed information on claims dispute
files to ensure appropriate and comprehensive data is returned to
the provider timely.
- Track issues and monitor trends to support their
- Identify potential/actual claims problems (single or
recurring/trending) and document root cause analysis; present
findings to management.
- Improve quality, enhance workflow, and provide efficiencies
within departments, identify opportunities for improvements;
develop and present recommendations for changes.
- Develop and maintain detailed understanding of rates as per
- Support departmental goals for cycle time by organizing and
tracking claims for review.
- Special projects as needed.
- Bachelor's degree required; additional years of experience
and/or training can be used in lieu of educational
- 2 - 3 years' prior related work experience in
professional/facility claims or benefits/billing environment
- Strong knowledge of claim processing policies and procedures
- Knowledge of medical terminology, ICD/CPT coding, per diem and
DRG reimbursement and EDP testing procedures required
- Proficiency with MS Office applications (word processing,
database/spreadsheet, presentation) required
- Ability to accurately interpret information from contractual
and technical perspectives required
- Must be conscientious and detail oriented, recognizing unusual
patterns and troubleshooting for operational improvement and
- Strong analytical and problem-solving skills required
- Ability to effectively work on multiple projects/tasks with
competing priority levels required
- Ability to effectively absorb and communicate information
- Strong Interpersonal and teamwork skills required
Keywords: Emblem Health, New Haven , Claims Review Analyst, Other , Melville, Connecticut
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