Senior Claims Analyst

Where compassion meets innovation and technology and our employees are family.

General Purpose of Job:

The Senior Claims Analyst will be responsible to perform highly complex and technical analysis for research, resolution and recover of health plan claims.  The position is also responsible to departmental and project coordination for issues resolution and process improvement, and helps to ensure that systems, processes and reports enable the Claims Administration department to meet internal and external benchmarks.  The position additionally serves as a subject matter expert regarding claims related policies and procedures.

Essential Duties and Responsibilities:

Individuals in this position may perform and or all the below listed duties.  These should be interpreted as examples of the work and are not necessarily all inclusive.

• Analyze highly complex claims and claim issues to ensues to ensure correct claims payment, partner with Claims Administration and staff and health plan business partners for resolution.
• Identify trends and recommend solutions for errors as identified through pre- and post-payment claim and recover review.
• Assist with department leadership to develop daily inventory plans based on available resources, priority, and timeliness requirements.
• Analyze provider correspondence and requests for review to determine correct outcomes and resolution, escalating high priority/risk issues to leadership.
• Lead departmental projects and/or operational improvement initiatives.
• Assist in the examination, assessment, and business documentation of operations and procedures to ensure data integrity, security, and process optimizations.
• Ensure adherence to state and federal compliance, reimbursement and contract policies.
• Provide mentoring and coaching to team members, provide assistance and feedback to less experienced staff members, and lead training efforts for new employees.
• Openly participate in team meetings, providing ideas and suggestions to ensure departmental efficiency and quality, and to promote teamwork.
• Maintain required compliance with privacy and confidentiality standards.
• Maintain or exceed all established standards for performance, quality and timeliness.
• Demonstrate business practices and personal actions that are ethical and adhere to all Health System and Health Plan policies and procedures.
• Assist with other related work responsibilities as requested.

Education and/or Experience:

Any combination of education and experience that would likely provide the required knowledge, skills, and abilities is qualifying.

• Minimum five years professional experience in claims analysis , provider medical billing, or medical coding experience with Texas Medicaid preferred.
• Minimum two years professional experience with Claim research, adjustment and recover; experience with Texas Medicaid preferred.
• Minimum High school graduate or GED required.