Medical Claims Analyst Contract
Primary Job Purpose: Provides medical claims processing. Investigates and applies contract benefits. Works with basic to more complex claims and meets department standards for quantity, accuracy, timeliness and dependability.
Minimum Job Qualifications and Technical Competencies: Four years job related work experience processing claims or related work experience. Demonstrated knowledge and ability to process STM claims and functions. Knowledge of medical terminology and coding. Ability to utilize claim investigative techniques to identify and evaluate claim information in a fair and objective manner. Detail oriented with ability to analyze and research contract information. Demonstrated ability to make balanced decisions with the highest degree of integrity and fairness. Ability to express ideas and recommendations clearly and with a high level of professionalism in written and oral communications. PC skills; ability to operate effectively in an imaged environment. Ability to work with others in a highly collaborative team environment. Demonstrated ability to multitask and balance goals and priorities. Excellent customer service skills. Problem solving skills. Basic math skills. Operating knowledge of claim payment system preferred.
General Functions, Outcomes and Duties: Determines from diagnosis and information received on the claim and supporting documentation whether the claim is eligible for payment under contract benefits or whether the claim should be further investigated. Reviews and researches the claim and requests additional information for medical review. Conducts pre-existing conditions investigations as appropriate. Analyzes, enters and investigates claims in order to process or reprocess claims in a timely and accurate manner. Applies knowledge of medical terminology, coding and other resources to resolve claims issues. Validates provider and service information. Contacts insurance companies, providers, agents/brokers, subscribers and other member representatives to obtain missing or incomplete information. Undertakes a timely and accurate claims review and initiates appropriate claim validation activities and recommends either initial approval of benefits or denial of the claim. Effectively articulates rationale for action when necessary. Prepares written correspondence that specifically references contract provisions that support the claim decision. Provides excellent customer service by paying appropriate claims promptly and quickly responding to all inquiries. Protects the Company against extra-contractual liabilities by following established guidelines and regulations. Participates in special projects and assignments as needed. Cross-trains on a variety of jobs to provide back-up capabilities as needed.