Claims Analyst- Tpa

Curative is searching for a Claims Analyst to review claims for completeness and process per plan guidelines. Carries out all duties while maintaining compliance and confidentiality and promoting the mission of the organization.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Reviews claims for compliance with plan guidelines and approves or denies payment using established guidelines, policy and procedures and plan directives. 
• Documents clearly and concisely claims adjudication decisions in Claim Notes. Consults appropriate reference materials to verify proper coding. 
• Ability to interpret and apply plan guidelines while processing to ensure correct plan setup. 
• Coordinates adjudication of claims against the eligibility of individual enrollees as well as authorizations and benefit verification. 
• Proactively identify processes and system problems than can be improved, to reduce rework and provide accurate payment upon original processing. 
• Maintains timely responses to appeals and reconsideration requests 
• Attends and participates in departmental training, functions, and meetings. 
• Ability to meet/ maintain the required accuracy and production standards after release from training. 
• Adheres to rules and regulations of Curative as described in the employee handbook and in the unit/department/clinic procedures 
• Performs other duties, functions, and projects, as assigned, by team management. Travel Requirements: None

REQUIRED EXPERIENCE 

• At least 5 years of experience in claims adjudication, including PPO and/or Medicaid, ERISA, Medicare, Level Funded and Self-Funded Experience with various claim payment systems in processing hospital, mental health, dental and routine medical claims within given deadlines. 
• Excellent Working Knowledge of MS Access, Google Sheets and Excel required 
• Knowledge of medical terminology, ICD-10, CPT, and HCPCS coding. 
• Excellent computer and keyboarding skills, including familiarity with Windows 
• Excellent interpersonal & problem-solving skills. 
• Excellent verbal and written communication skills to communicate clearly and effectively to all levels of staff, members, and providers. 
• Ability to be focused and sit for extended periods of time at a computer workstation. 
• Ability to work in a team environment and manage competing priorities 
•  Ability to calculate allowable amounts such as discounts, interest, and percentages

REQUIRED EDUCATION, LICENSES and/or CERTIFICATIONS 

• High school diploma or equivalent.