Claims Research Analyst
15950 North 76th Street Scottsdale, AZ 85260
- This position serves as point of contact and subject matter expert for research and remediation of system and claim issues working with other departments as required to complete financial impact analysis, as well as the review and release of claim financial holds.
- This position is responsible for monitoring regulatory changes related to claims payment or administration and researches and analyzes projects and correspondences. Identify systems, configuration and processing problems, errors and trends.
- Responsible for communicating any changes needed to appropriate stakeholders and assisting with implementation of these changes.
- Role is responsible for claims research and for oversight audits to ensure processed claims are in compliance with departmental policies, procedures and claims financial liabilities.
- Review adjudicated claims to determine appropriate levels of completeness, accuracy and timeliness are met.
- Function as technical specialist for claims enhancements operations.
- Analyze complex operational claim payment problems and provide technical solutions.
- Identify and recommend areas where changes to existing processes and procedures can result in process and/or cost savings.
- Provide support to various claims staff.
- Respond to and resolve claim inquiries.
- Provide documentation, as appropriate, to support claim resolution.
- Maintain a current working knowledge of processing rules, contractual guidelines, plan policies and operational procedures to effectively provide technical expertise.
- Identify process gaps and trends; then provide explanations and feedback to staff and management.
- Identify key issues with projects and offer solutions.
- Provide technical and peer in-service training.
- Conduct cross training and act as mentor to staff as required.
- Serve as a subject matter expert as needed.
- Audit claims from various sources.
- Report on accuracy in the areas of adjudication errors.
- Re-process claims as needed.
- Perform validation of claims from an overall perspective, including the validity of the data entry process, the analyst’ s adjudication process, the investigative process, and the validity of the enrollment process. Identify claims that appear suspicious to management for further investigation.
- Monitor work processes and confirm that they are in agreement with policies and procedures.
- Answer claims adjudication and/or system questions.
- Serve as a resource regarding claims processing procedures.
- Other duties as assigned.
For more information on this position, please contact our office at 877-782-3334.