Medical Claims Analyst Job Description

Medical Claims Analyst Job Description

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Medical claims analyst provides guidance to examiners regarding general and specific claim issues, interpretation of policy contracts and terminology.

Medical Claims Analyst Duties & Responsibilities

To write an effective medical claims analyst job description, begin by listing detailed duties, responsibilities and expectations. We have included medical claims analyst job description templates that you can modify and use.

Sample responsibilities for this position include:

Regular use of Microsoft Word, Excel, PowerPoint, in support of project documentation and communication needs
Researches local billing and reimbursement policies, client reimbursement practices (through review of manuals/regulations and meetings with stake holders) to develop and configure overpayment algorithms
Reviews provider contracts to identify algorithms for the identification of fee schedule and other contractual based overpayments
Performs scoping analysis and development of new overpayment algorithms using SQL coding
Develops specifications for IT programming related to developed overpayment algorithms and analysis
Assists in preparing presentations and proposals to internal and external clients
Understand where, when and how professional resources both internal and external, medical, investigative and legal can add value to the process
Manage Real Time exceptions in a large call center environment
Provide communication to and from Operations and other support departments for escalation of service-impacting issues
Oversee call flow, real time, through workforce management tool

Medical Claims Analyst Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Medical Claims Analyst

List any licenses or certifications required by the position: CCS, CPC, THIT, RHIA

Education for Medical Claims Analyst

Typically a job would require a certain level of education.

Employers hiring for the medical claims analyst job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Collage Degree in Business/Administration, Business, Healthcare, Education, Law, Legal, Legal Assistant, Medical, Associates, Economics

Skills for Medical Claims Analyst

Desired skills for medical claims analyst include:

Excel
Various major provider accounts receivable systems
Claim payment system
Coding and other resources to resolve claims issues
Current payer specific reimbursement regulations and remain abreast of changes to policy through client websites
Medical terminology
Medical terminology and coding
ASA
Affordable Health Care Act
CPT

Desired experience for medical claims analyst includes:

Medical claims analysis or interpretation experience
Associate’s or Bachelor’s Degree in Business or Applicable field
2 or more years of previous technical, claims processing or subrogation experience
Able to Manage and Analyze data, run reports and interpretation of results
Able to think out of the box, while researching and investigating possible overpayment ideas
2 or more years of previous technical, claims analysis and processing

Medical Claims Analyst Examples

1

Medical Claims Analyst Job Description

Job Description Example
Our innovative and growing company is looking to fill the role of medical claims analyst. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for medical claims analyst
  • Completes real time activities related to staffing –Ensures that recommendations for appropriate adjustments to leverage, skillchanges are occurring, as required
  • Ensures that service level reports to scan for issues and anomalies, and reports perceived concerns to the Team Manager and/or client.(According to established escalation process)
  • May conduct manual studies or analysis due to system short-falls
  • Analyzes real-time schedule efficiency measurements key indicators such as service level, for continuous improvement
  • Facilitate the transfer of information of helpdesk requests from Agents to technical support and ensures escalation on large-scale orglobal technical problems
  • Ensures that appropriate exception codes are entered to maintain accurate real-time monitoring data
  • Investigation of any deviations and enter exceptions in real time
  • Work with Human Resources, Recruiting, and Training to coordinate the ID creation of new employee resources
  • Help facilitate the ID Request process for System Access for all new hire, transfer, promoted and terminated employees, as needed
  • Communicate with new hires on schedule process, as needed
Qualifications for medical claims analyst
  • Good writing skills, ability to develop presentations, brief proposals, protocols, and review guideline documents
  • 3+ years of healthcare reimbursement experience such as provider contract development, healthcare claims analysis, medical billing/coding, patient accounting, claims auditing, and/or revenue cycle improvement
  • Of mature disposition and personable
  • A minimum of 5 years of medical malpractice and professional liability claims experience
  • Strong written and verbal communication skills along with strong negotiation, litigation management and interpersonal skills
  • Excellent organizational and computer skills combined with the ability and flexibility to work in a dynamic, challenging and fast-paced environment
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Medical Claims Analyst Job Description

Job Description Example
Our company is hiring for a medical claims analyst. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for medical claims analyst
  • Maximize efficiency and occupancy while meeting service objectives
  • Adjudicate medical claims in accordance with the medical plan document(s), administrative procedures, and software procedures
  • Initiate corrective measures on claims processed incorrectly including requesting refunds, reprocessing claims with corrected information, and ensuring that all plan and administrative procedures regarding claims corrections are followed
  • Provide back up to the Medical Claims Center’s Customer Service call lines
  • Apply medical knowledge to research and respond to complicated claim and provider questions
  • Assist in medical claim center administration in regard to repricing and other projects as assigned
  • Maintain accurate project time logs to facilitate studies regarding claims volume capabilities
  • Actively participate in continuous improvement efforts including initiating ideas to improve the quality and/or efficiency of the work performed in the Medical Claims Center
  • Evaluate, analyze and recommend procedure coding guidance to support claim remediation efforts in cross-functional forums where coding issues are identified
  • Analyze health plan claim denials and rejections and work with claims operations team to identify and remediate situations where CARC/RARC codes are associated with fee schedule or coding errors
Qualifications for medical claims analyst
  • Exposure to all insurance lines and claims involving the London ceded market helpful
  • Ability to navigate within computer system environments without assistance
  • Minimum five (5) years related insurance experience, required
  • Medical malpractice insurance experience strongly preferred
  • Minimum of 1 year forecasting and schedule and real-time adherence management experience (Mastery / CLEAR understanding of workforce management principles
  • Ability to work independently (or as a team) and understand the impact of decisions made
3

Medical Claims Analyst Job Description

Job Description Example
Our company is hiring for a medical claims analyst. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for medical claims analyst
  • Quantify trends leveraging claims data which are negatively impacting expected payment or financial performance to lead collaboration and root cause analysis with cross-functional teams to drive improvement
  • Establish standard medical coding guidelines for CareCentrix products defined by industry guidance published by CMS, AMA, or other governing or regulatory organizations, with clear documentation of supporting authority
  • Perform ongoing independent research related to changes in industry standard medical coding and impact analysis with a focus on claims processing, potential internal and external stakeholder process changes which may be required
  • Maintain CCX standard coding artifacts affected by changes implemented by governing bodies, new services to market, product enhancement or tailoring efforts or in support of new product development and develop education and communication materials for cross-functional audiences
  • Evaluate all proposals which include procedure coding and provide a recommendation to align with regulatory/compliance, financial, and claims operational perspectives to support stakeholder requests
  • Establish and maintain cross-functional relationships to address claims coding and associated rule issues facing the organization
  • Troubleshoot software error reports, clearinghouse rejections
  • Responsible for providing enterprise-wide reporting and oversight of federal and state regulatory implementation, compliance and exam activities
  • Participates in enterprise-wide efforts to improve responsiveness to and consistency of company responses to market conduct exams, and provides enterprise-wide reporting on exam status, penalties and trends
  • Obtains and maintains an awareness of industry regulatory trends, organizational developments, and company strategies that could impact the success of regulatory projects
Qualifications for medical claims analyst
  • High proficiency in other MS Office products
  • Commitment to confidentiality and customer service
  • Strong attention to details and the ability to process high volumes of work quickly and accurately
  • Good time management and the ability to work within deadlines
  • Analytical/investigational reasoning and problem-solving skills
  • Above average keyboarding skills (speed and accuracy)
4

Medical Claims Analyst Job Description

Job Description Example
Our company is growing rapidly and is searching for experienced candidates for the position of medical claims analyst. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for medical claims analyst
  • Provides support to the Civil Health Care Fraud Coordinator, ACE Supervisory Investigator and several Assistant United States Attorneys (AUSAs) in furtherance of complex and high profile affirmative civil enforcement cases
  • Provides expert claims data, statistical and financial analysis in support of complex civil fraud investigations, including, without limitation, health care fraud
  • Coordinates with USAO Information Technology (IT) and Automated Litigation Support (ALS) sections regarding modification of standard systems, to resolve hardware and software problems, and to adapt precedents or make significant departures from standardized approaches to meet user requirements
  • Cases handled are complex and require in-depth data analysis to help provide patterns of fraud by organizing, tracking and analyzing thousands or hundreds of thousands of items of evidence, millions of data elements, and may involve untried or especially novel computer or digital imaging applications
  • Consults with and advises case teams on best practices for the preparation of documents and how to best use data analysis to support cases
  • Assists attorneys with production of electronic data/material both to and from external parties
  • Reviews, analyzes and summarizes case data
  • Analyzes Medicare, Medicaid, and private insurer databases for potential indicators of fraud and abuse
  • Change written off in excess of amounts actually billed
  • Identification of refund trends that can be applied across contract base to maximize revenue
Qualifications for medical claims analyst
  • Experience with menu driven system applications
  • Must have ICD-10 and DRG coding experience
  • Management or team leadership experience, desired
  • Strong knowledge of ESI Policy & Procedures
  • Strong attention to detail and good retention skills
  • Self-motivated and ability to effectively prioritize multi tasks and deadlines
5

Medical Claims Analyst Job Description

Job Description Example
Our company is growing rapidly and is hiring for a medical claims analyst. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for medical claims analyst
  • Delivers summary reports to Providers on results of project work and their corresponding revenue implications
  • Interpret and apply contract language through claim adjudication process
  • Consults with Providers troubleshooting Client issues
  • May assist with training and mentoring new and current auditors
  • Provides on-site and remote financial account analysis
  • Identify appropriate assignment of ICD-10-CM and for services provided in a hospital setting and understand their impact, while adhering to the official coding guidelines and established client coding guidelines of the assigned facility
  • Additional responsibilities as identified by manager
  • Review and process all incoming claim referrals
  • Communicate with staff and Account Coordinators (AC) to gather pertinent claim information as assigned
  • Contact facilities to obtain information needed to process claims
Qualifications for medical claims analyst
  • Ability to work in fast-paced, production environment
  • Analytical mind and the desire to follow a project through to completion
  • Coding certification (CPC-P, CPC-A minimum) preferred or obtained within 12 months of employment for candidate with commensurate experience
  • 4 + years of experience to demonstrate proficiency in medical coding, billing, and claim requirements, including a working knowledge of industry guidelines and resources
  • Knowledge of health insurance or HMO operations with emphasis on claims processing, system set up and auditing software
  • Ability to positively communicate with coworkers

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