Address
Form of workWe are currently hiring a remote Claims Analyst! If you are a knowledgeable, passionate, detail-oriented individual with healthcare billing experience, and value being part of a team that makes a difference, you may be the right person for the position! Apply today!
JOB SPECIFICATIONS
Classification: NON-EXEMPT | Status: FULL-TIME, Monday - Friday, generally 8am to 5pm, Pacific Time
Salary: $17.00 - $24.72/HOUR
Department: CLAIMS | Work Location: REMOTE | Reports to: CLAIMS MANAGER
Supervision Exercised: NON-SUPERVISORY
JOB PURPOSE: Healthcare Claims Analyst
This position is responsible for the review and analysis of medical claims (with a strong focus on claims billed on a UB04/837I format) for accuracy and completeness and the adjudication of claims using the appropriate contract benefits. This position also responds to incoming provider inquiries in a professional, timely manner.
QUALIFICATIONS, EDUCATION, and EXPERIENCE
- High school diploma or GED equivalent required
- Knowledge of facility and professional pricing methodologies like DRG, case rate, per diem, % of billed, fee schedules, etc. is required
- Three years of experience with Healthcare Claims billing or adjudication experience preferred
- Experience with inpatient and outpatient facility billing (UB04/837I) preferred
- Coding and billing certification strongly preferred (CPC, CPB, COC, CIC, CCS, CCA)
- Will give preference to certified applicants or applicants who are currently obtaining certification
ESSENTIAL RESPONSIBILITIES: Claims Adjudication
- Understand Oregon Health Plan benefits, company policies, and Plexis Quantum Choice claims payment program
- Process institutional and professional claims, utilizing CMS pricer, Visium, Encoder Pro, and knowledge of payment methodologies (DRG, APC, ASC, SNF-RUG, etc)
- Answer inbound calls and respond to provider inquiries about claim status and adjudication
- Adjust claim payments when necessary
- Apply guidelines for surgical centers, CPT codes, HCPCS, REV codes, ICD-10, NCCI Edits, National Drug Code, and other code sets
- Analyze and adjudicate claims in line with Health Plan Contract and company policies
- Pay, pend, or deny claims based on eligibility, referral/prior authorization, COB, medical review, and claims policy
- Research and review claims that need additional data, coordinating with billing offices as required
- Deliver exceptional customer service, addressing plan coverage and payment inquiries
- Ensure timely response to inquiries, document interactions, and conduct necessary research
- Identify and correct errors, handle overpayments, and issue refund requests
- Maintain comprehensive documentation of claim decisions via phone, email, fax, and courier
- Cross-train in various department functions to enhance efficiency
- Participate in quality and organizational process improvement activities and teams as requested
- Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
- Handle confidential information and materials appropriately and maintain a secure work area
- Perform other assigned duties
ESSENTIAL RESPONSIBILITIES: Communication & Teamwork
- Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner
- Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization
- Provide excellent customer service to all internal and external customers
- Detail oriented and strive for accuracy in all functions of the department processes
ESSENTIAL RESPONSIBILITIES: Professional Development
- Recognize new developments and remain current in claim analysts best practice standards and anticipate organizational modifications
- Advance personal knowledge base by pursuing continuing education to enhance professional competence
- Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
- Represent organization at meetings and conferences as applicable
KNOWLEDGE, SKILLS, and ABILITIES
- Comprehensive knowledge of medical claims, Oregon Health Plan eligibility data elements, and relevant coding systems and code sets (CPT, HCPCS, ICD-10, National Drug Code, etc)
- In-depth knowledge of facility claims billing and reimbursement methodologies for various healthcare settings (inpatient, outpatient, skilled nursing facilities, ESRD facilities, home health, hospice)
- Familiarity with the components of DRG pricing (DSH, IME, DME, etc.)
- Proficiency in medical terminology
- Utilization of fee schedules and designated resources, including the Oregon Health Authority Prioritized List, Centers for Medicare and Medicaid Services (CMS), Oregon Health Authority (OHA), and DOCS Management Services guidelines and apply those resources to accurately process claims
- Comprehensive grasp of company policies, procedures, and transactional payment systems
- Strong problem-solving abilities, including identifying issues, recommending solutions, and organizing and analyzing information
- Attention to detail and organizational skills for accurate processing
- Knowledge and understanding of how the positions’ responsibilities contribute to the department and company goals and mission
- Knowledge of federal and state laws including OSHA, HIPAA, Waste Fraud and Abuse
- Awareness and understanding of equity, equity lens, diversity, and inclusion
- Training in or awareness of Health Literacy, Poverty Informed, Systemic Oppression, language access and the use of healthcare interpreters, uses of data to drive health equity, Cultural Awareness, Trauma-Informed Care, Adverse Childhood Experiences (ACEs), Culturally and Linguistically Appropriate Service (CLAS) Standards, and universal access
- Proficient in Microsoft Office Suite and Windows Operating System (OS)
- Non-judgmental attitude
- Identify problems, recommend solutions, organize, and analyze information
- Excellent customer service skills
- Adaptability to report to work as scheduled and willingness to work a flexible schedule when needed
- Awareness and understanding of equity, diversity, inclusion, and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social, political, and environmental contexts of policies, programs, and practices
- Excellent people skills and friendly demeanor
- Critical thinking skills of using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems
- Ability to handle stress and sensitive situations effectively while projecting a professional attitude
- Ability to communicate professionally, both conversing and written
- Ability to work with diverse populations and interact with people of differing personalities and backgrounds
- Sensitive to economic considerations, human needs and aware of how one’s actions may affect others
- Ability to organize and work in a sensitive manner with people from other cultures
- Poised; maintains composure and sense of purpose
WORKING CONDITIONS
This position must have the ability to remain in a stationary position, occasionally move about inside the office to access office machinery, printer, etc., frequently communicate and exchange accurate information.
Work Condition: Remote Environment
- Employee generally works within a remote work from home environment.
- Travel may be required on occasion.
- Hours of operations and specific staff scheduling may vary based on operational need.
- Exposed to:
- Employee is responsible for maintaining a safe work environment that is conducive to successful productivity and work output.
- Machines, equipment, tools, and supplies used: Constantly operates a computer or other office productivity machinery or software, such as fax, copier, calculator, multi-line telephone system, or scanner.
- May answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain or record information.
- Multiple Duties: Must be able to work under conditions of frequent interruption and be able to stay on task.
This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of DOCS Management Services employees. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.
