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Job Summary

CLAIMS ANALYST

The Claims Analyst is responsible for the accurate adjudication and processing of medical, dental, vision, or other related claims, including related correspondence and/or electronic inquiries for assigned groups. All claims and inquiries are handled according to the established plan documents, claim processing guidelines, and established total turnaround times.

CLAIMS ANALYST

80% 

Review, analyze and interpret claim forms and related documents.  

Determine benefit coverage based on clinical edits, plan documents/booklets, benefit reference documents, Claim Reference Manuals and claims-related memoranda, and reports. 

 Appropriately investigate, pend and refer claims based on claim procedures and guidelines. 

Accurately handle correspondence, claims, and referrals in the established timeframes and/or performance guarantees. 

Support the Claims reinsurance team, in the research and resolution of claims as assigned 

 

15% 

Support internal departments in the research and resolution of claims 

Communicate via telephone, email, electronic messaging, fax, or written letter with employees/members, providers of service, clients and/or other insurance carriers to ensure proper claim processing 

5% 

Other duties as needed/assigned 

​Customer Service – Research and respond to a high volume of customer service phone calls within stated time specifications, following established department guidelines.  Ability to work with other team members in management of customer service calls.  Resolve issues through effective oral and written communication and by involving appropriate people within, or outside, the department or Company.  Effectively and professionally represent the Company in all interactions.


Resource Development/Training – Provide support, training and back-up to the Claims Assistant and other team members, as needed.  Assist in establishing procedural manuals and keeping procedure documents current and up to date. 

Other – Continually improve claim and system knowledge and communication skills.  Continue to utilize knowledge gained on the job.  Perform all reporting functions as assigned.  Participate on special projects and other job related duties as assigned.

CLAIMS ANALYST

Required Job Qualifications:

High School diploma or GED equivalent
Ability to work in a fast-paced, customer centric and production driven environment
Effective verbal and written communication skills
Ability to work effectively with team members, employees/members, providers, and clients
Ability to use common sense understanding to carry out instructions furnished in oral, written or diagram form
Flexible; open to continued process improvement
Ability to learn new/proprietary systems, to adapt to various system platforms, and to effectively use MS Excel/Word


Preferred Job Qualifications:

1 year Health Insurance experience
Self-Funded Insurance/Benefits and/or TPA experience
Knowledge of medical procedure and diagnosis coding
Knowledge of medical terminology
Familiarity with Summary Plan Documents (SPDs)/Insurance Booklets or other benefit descriptive tools


LIFE & DISABILITY - CLAIMS ANALYST
Required Job Qualifications:

An understanding of claims examining; solid investigation, analytical and organizational skills, and attention to detail.  
Must have strong math and decision-making skills.
Must be able to work in a deadline driven, fast-paced environment.
Self-motivated with high learning agility.
Must have excellent verbal and written communication skills with a passion for helping others.
Must be a self-starter with strong time management skills to prioritize workload, manage and follow-up on numerous tasks.    
Capable of making decisions in the absence of specific directions with minimal supervision.
Ability to effectively cope with change and shift gears accordingly in a dynamic environment. 
Must display a strong commitment to teamwork and have the ability to work in a collaborative environment.
Effective in the use of personal computers and related software.  Proficiency in working with Word, Excel and Outlook.
High School diploma or GED equivalent


Preferred Job Qualifications:

Four-year college degree in medical and/or business field.
Life and/or Disability claim knowledge