Employer: Lumeris
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Position:
Claims Analyst (Remote)
Position Summary:
The Claims Analyst is a part of the Services team and is responsible for researching and processing moderately complex claims. These claims are both paper and electronic and follow CMS guidance. The Claims Analyst applies specific and market focused processes to provide service support to clients as needed. This role includes solving claims issues, detailed reporting, adjustments and escalations.
Job Description:
Primary Responsibilities
- Investigates and processes moderately complex claims.
- Handles difficult situations and acts with appropriate level of urgency when necessary.
- Follows precise instructions when processing claims.
- Completes assigned work and maintains production and quality standards.
- Extensively collaborates cross-functionally to support resolution of claim issues.
- Researches and resolves adjustment inquiries.
- Performs edit resolutions from pended paper and electronic claims using critical sense of urgency and sound judgement for accurate claims processing.
- Works complicated reports, which involves critical resolutions on adjustments, overrides of copayments, coinsurance, correct pricing and provider selection.
- Performs side by side comparisons to validate corrected claim actions.
- Issues letters & forms when appropriate.
- Performs initial overpayment recoupment process in the overpayment application.
Qualifications
- High school diploma or general education degree (GED)
- 1+ years of experience in a related role
- Basic knowledge and understanding in operational processes and complicated pricing calculations for medical/hospital claims processing
- Demonstrated experience researching and understanding moderately complex information (such as government regulations, contracts, etc.), as well as solving ambiguous problems
- Strong attention to detail
- Ability to work in a fast-paced environment with multiple high priorities
- Flexibility and adaptability to frequently changing guidelines and processes
- Ability to learn and maintain knowledge of medical benefits and how they are administered and Medicare fee schedules, as well as Federal, State, and local healthcare regulations
- Collaboration skills and the ability to communicate effectively through both written and verbal modalities
- Proficiency with business applications like Microsoft Office Suite
- Experience working with 10-key and excellent keyboarding skills
- Critical thinking, problem-solving, and investigatory skills
Preferred Qualifications
- Experience in Claim Processing is a plus
- Bachelor’s degree preferred
Working Conditions
- While performing the duties of this job, the employee works in normal office working conditions.
Disclaimer
- The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.
Lumeris is an EEO/AA employer M/F/V/D.
Location: United States
Time Type: Full time
Lumeris and its partners are committed to protecting our high-risk members & prospects when conducting business in-person. All personnel who interact with at-risk members or prospects are required to have completed, at a minimum, the initial series of an approved COVID-19 vaccine. If this role has been identified as member-facing, proof of vaccination will be required as a condition of employment.
Member Facing Position: No- Not Member Facing Position