Claims Adjustment Analyst

Department: Claims Operations

Location: Houston, Tx

Job Title: Claims Adjustment Analyst

Reports to: Director

General Description/PURPOSE

The Claim Adjustment Analyst review and adjudicate claim adjustments received through Customer Service, reconsiderations, refunds and/or recovery requests, along with any other assigned duties while maintaining production and claim accuracy standards.

COMPANY GENERAL POLICY AND PROCEDURE

- Attendance: Is punctual and present. Will request time off in accordance with policy. Will document time worked and reasons for tardiness/absence or leaving early according to office policy.

- The requirements listed below are representative of the knowledge, skill, and/or ability required. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The competence of the employee in performing his or her job duties will be demonstrated, maintained, and improved on an ongoing basis.

- The statements contained in this position description reflect the general duties considered necessary to describe the principal functions of the job as identified and shall not be considered a detailed description of all the work requirements that may be inherent in the position.

JOB RESPONSIBILITIES

- Review, research, investigate and adjust hospital and physician claims.

- Review and interpret provider issues related to payment adjustment.

- Able to interpret and apply SCA’s (Single Case Agreements) and other reimbursement methods.

- Review of returned checks and perform back out process of both providers return checks and refunds received; document member history as needed.

- Maintains current desk procedures and reference materials.

- Works with claims management in review of special projects

- Any other assigned duties

Financial Management

- Work within approved budget; uses cost saving measures; contributes to profits and revenue.

- Receive all appropriate approvals (e.g., purchase orders, expense reports) for incurred expenses

Customer Service

- Interact with all visitors and fellow employees in a mature, responsible, courteous manner to ensure a positive and professional environment. Responds promptly to customer and coworker needs, and continually strives to improve service.

- Maintain sensitive information in a confidential and professional manner.

REQUIRED QUALIFICATIONS

High School diploma or equivalent.

3 years of complex medical claims adjudication experience in a HMO, PPO, or TPA experience.

Understanding of medical terminology, CPT and ICD9 Coding and billing forms (HCFA/UB-04).

Strong knowledge of Medicare claims processing guidelines.

Strong knowledge of Medicare payment methodologies.

Ability to interpret and apply contracts, Single Case Agreements, fee schedules, and reimbursement methods.

Knowledge of Medicare Secondary Payer regulations.

Ability to create KPI’s.

Ability to demonstrate analytical skills.

REQUIRED SKILLS

Proficiency in using Microsoft Office suite, with advanced Excel spreadsheet skills.

Self-directed and able to absorb new material quickly.

PHYSICAL REQUIREMENTS

While performing the duties of this Job, the employee is regularly required to talk or hear. The employee is frequently required to sit and use hands and fingers, handle, type, or feel. The employee is occasionally required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision and distance vision.

Machines/Equipment Used

Computers, copy machines, telephone, fax machine and other equipment as necessary

Environmental Conditions

Indoor climate-controlled environment; occasional exposure to outdoor climate. Moderate to quiet noise level.

Company Benefits

In a full-time permanent position, you will be able to participate in our company benefit program which includes:

• Group benefits include medical, dental, vision, company-paid $25k life with the option to add more voluntary life insurance coverage for employee and their family, STD, company paid LTD, 401k matching, and a variety of supplemental coverages such as hospital, cancer, legal, etc. available to the employee and their family.
• Employee funded FSA program.
• Paid Time Off ranging from 5-28 days depending on length of service.
• Profit Sharing Bonus Program
• 100% Employer Paid Pension Plan after 5 years
• Access to company gym and locker rooms in Houston offices

Job Type: Full-time

Pay: $55,000.00 - $70,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible schedule
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift

Work setting:

• In-person

Work Location: In person