Claims Review Analyst - Emblem Health

• Support contract performance management of a large health system.
• Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on
contractual and industry guidelines.
• Identify and analyze single issues and trends to determine root causes.
• Provide recommendations for solutions to minimize errors and delays in systems and/or processes.
• Monitor system output to ensure proper functioning.

Principal Accountabilities

• Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims
review.
• Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is
returned to the provider timely.
• Track issues and monitor trends to support their resolution.
• Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present
findings to management.
• Improve quality, enhance workflow, and provide efficiencies within departments, identify opportunities for
improvements; develop and present recommendations for changes.
• Conduct regular meetings with the assigned provider groups for status of AR files and recycles
• Support departmental goals for cycle time by organizing and tracking claims for review.
• Monitor and provide timely responses for the designated provider group emails and AR files.
• Perform other related tasks as directed or required.

Education, Training, Licenses, Certifications

• Bachelor's Degree.

Relevant Work Experience, Knowledge, Skills, and Abilities

• 2 - 3 years' prior related work experience in professional/facility claims or benefits/billing environment required
• Additional experience/specialized training may be considered in lieu of educational requirements required
• Strong knowledge of claim processing policies and procedures required
• Knowledge of medical terminology, ICD/CPT coding, per diem and DRG reimbursement and EDP testing procedures required
• Proficiency with MS Office applications (word processing, database/spreadsheet, presentation) required
• Ability to accurately interpret information from contractual and technical perspectives required
• Must be conscientious and detail oriented; ability to recognize unusual patterns and troubleshoot for operational
improvement and efficiencies required
• Strong analytical and problem-solving skills required
• Ability to effectively work on multiple projects/tasks with competing priority levels and deadlines required
• Ability to effectively absorb and communicate information required
• Strong Interpersonal and teamwork skills required

Additional Information

• Requisition ID: 1000000576
• Hiring Range: $55,000-$65,000