The nearly 185 employees of Neighborhood come from diverse backgrounds, but are all committed to creating a more equitable health care system. Our array of experiences allows us to have a broad perspective and great creativity in facing whatever challenges arise. Unlike many other health insurance companies, we have nearly 30 nurses and social workers on staff - and zero actuaries. This structure speaks to our focus on active and compassionate care management for our members; we know that people who are alienated from the health care system require additional advocacy, outreach and support.

Claims Analyst I - Temp. 18 Month Assignment

Claims Analyst I - Temp. 18 Month Assignment

 

POSITION TITLE:   Claims Analyst I         DEPARTMENT: Operations

      

 

Overview:

 

The role of the Claims Analyst is to ensure that claims are processed according to state and federal regulations and meet NHPRI’s contractual obligations. 

 

 

Qualifications:

 

Required:

·  High school graduate or equivalent

·  Experience using industry standard coding

·  3 - 5 years claims processing or medical billing experience is required with 1 year minimum experience as claims analyst/examiner

·  Strong verbal and written communications skills

·  Excellent Customer service skills

·  Ability to effectively prioritize and execute tasks in a high-pressure environment is crucial

·  Mathematical skills and detail accuracy

·  Ability to work both independently and as a team member

Preferred:

·  Bachelor’s Degree

·  Experience with Medical Terminology

 

 

Duties and Responsibilities:

Responsibilities include, but are not limited to the following:      

 

·  Responsible for the entry, review and adjustment of claims within the Diamond system.  While performing data entry, employee will determine to pay, deny or hold claim.  Responsible for all research to fully adjudicate each claim

·  Review, investigate, and release medium to high complexity claims that have been placed on hold

·  As claims are released from hold, review all claims information previously keyed to ensure accuracy

·   Responsible to determine if correct billing/coding rules have been followed during the claims review process

·  Identify, research, and process claims which is a result of COB, forward new leads to person responsible for COB identification

·  Complete daily activity logs

·  Review medium to high complexity daily reports for claims processing and generate/resolve others reports as necessary

·  Responsible for the processing of member refunds, employee claims and transplant cases

·  Review weekly report of Emergency claims that have been denied to ensure appropriateness

·  Handles phone calls, faxes or paper inquires that are received in the office from providers, facilities and internal customers.  Will research and resolve problems as a result of those calls

·  Work with authorization staff when authorizations need corrections for claims processing

·  Daily analysis of workflow to meet targets, including distribution of workflow to Claims Analyst staff

·  Identify and communicate claims system and/or billing problems to the Team Leader and/or Manager

·  Assist in training of other claims staff

·  When necessary, assist with the numbering (provider/vendor) of claims that are received in order to send them out for data entry

·  Special projects as assigned

 

Neighborhood is an Equal Opportunity Employer

To apply, please visit our website: www.nhpri.org