Claims Analyst

SIHO HOLDING INC•Columbus, IN

1d•Onsite

About The Position

This is a non-exempt position responsible for reviewing, analyzing, and adjudicating non-routine health claims that could not be system adjudicated for payment. Analyst must research and interpret summary plan description language and make accurate determination for adjudication or denial of claim. Analyst must also assist in determining cause for manual intervention, then assist in writing logic and workflow automation for future claims.

Requirements

Post-secondary education or two years experience in a claims processing environment
Excellent communications (oral and written) skills
Intermediate skill levels in Microsoft Word, Excel, and Outlook preferred
Ability to work at a self-directed pace in a changing, multi-task environment
Detail oriented
Professional appearance and presence
Commitment to support and maintain confidentiality in conformance to HIPAA guidelines
Confirmation of excellent attendance record in current or most recent job
General knowledge and understanding of claims processing functions

Nice To Haves

Experience in Medicare Advantage strongly preferred

Responsibilities

Review incoming medical, pharmacy vision and dental claims
Determine and apply appropriate health plan benefits and update claims for payment
Ensure timely and accurate claims adjudication
Follow company guidelines and policies for adjudicating claims and responding to members
Act as a resource for questions, opportunities, and research issues for all internal and external customers
Responsible for meeting performance measurement standards for productivity and accuracy
Identify and resolve operational problems using defend processes, judgment, and expertise
Provide feedback to team members regarding process improvement opportunities
Asset with training and mentoring of new team members
Resolve identified claims issues based on CCI edit repot to comply with CMS guidelines.
Represent the department when needed for internal and external company meetings
Complete special projects (including research) as assigned by Claims Supervisor or Director of Claims
High level understanding of state and federal laws specific to health plan administration (HIPPA, ERISA, MHPAEA, ACA Mandates etc.)
Develop and maintain statistical data as required
Assist in departmental reporting