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Claims Analyst

    • Job Tracking ID: 512689-614005
    • Job Location: Milwaukee, WI
    • Job Level: Mid Career (2+ years)
    • Level of Education: 2 year degree
    • Job Type: Full-Time/Regular
    • Date Updated: March 28, 2018
    • Years of Experience: 2 - 5 Years
    • Starting Date: ASAP
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Job Description:

This professional position is responsible for researching, examining and responding to claims processing issues in a timely manner, including provider claims projects, complicated and unusual claims. Providing input and making recommendations for solutions to departmental and interdepartmental issues. Being responsible for resolution and handling of provider appeals according to iCare policy. Being responsible for researching and resolving member billing issues. This position reports to the Claims and Provider Relations Manager.

 

Essential Duties and Responsibilities:

 

  1. Coordinate exchange of provider information with appropriate iCare vendors. (Claims, Pharmacy, Subrogation and Cost Saving)

  2. Respond in a timely fashion to provider questions and issues regarding claims payment, in the form of reconsiderations, formal appeals and member bills.

  3. Interface with iCare/TriZetto personnel to establish and document claims processing, pricing and network policies and procedures.

  4. Provide prompt, courteous and excellent service to internal and external customers at all times.

  5. Research and examine problem claims to determine the cause of the claim’s problem status. Escalate trends and educational opportunities to the appropriate contacts.

  6. Handle complicated or unusual claims and resolves provider issues.

  7. Exercise proper judgement on questionable claims (i.e. timely filing and high dollar exceptions).

  8. Resolve/handle provider appeals according to iCare policy/procedures.

  9. Provide input and make recommendations for solutions to departmental and interdepartmental problems.

  10. Understand the enrollment, benefit and authorization process as it relates to claims.

  11. Work jointly with Finance and IT to resolve claims related encounter errors.

  12. Assist with the documentation of interdepartmental procedures.

  13. Participate in claims related audits initiated State, CMS or outside vendors.

 

 

Experience and Skills:

  1. Associate degree and equivalent experience in medical, medical records or insurance environment.

  2. 1-3 years claims experience in HMO or insurance environment.

  3. Ability to analyze all facets of complex claim situations and resolve them using empathy, tact and judgement.

  4. Hands-on PC or CRT experience to include knowledge of data entry, word processing and spreadsheet applications. Demonstrated use of Microsoft Office applications such as Access, Excel, Word, and Outlook.

  5. Proven analytical skills and detail oriented ability.

  6. Experience with multiple product lines preferred (HMO, Medicaid, and Medicare).

  7. Working knowledge of managed care contractual provisions.

  8. Working knowledge of medical terminology, CPT-4 procedure ICD-9 diagnosis codes, and DRG experience

 


 

 
 
 
  • Independent Care Health Plan
  • 1555 RiverCenter Drive, Suite 206
  • Milwaukee, WI 53212
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