Claims Analyst

Role Overview

• 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.
• 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.
• 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.
• Provide responsive and caring customer service.
• 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.

Requirements

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

Benefits

• Health insurance
• 401(k) savings plan
• Pension plan
• Paid time off
• Paid parental leave
• Disability insurance
• Supplemental life insurance
• Employee assistance program
• Paid holidays
• Tuition reimbursement
• Other incentives