Claims Analyst I

GENERAL DESCRIPTION: Analyze and process simple or non-complex professional and institutional claims, including data entry, adjudicating payments, declining payments, and requesting additional information, by following the benefits and requirements outlined up to the adjudication limit amount specified in the current policies and procedures. ESSENTIAL FUNCTIONS: Receives, posts, records in the inventory, and archives the claims assigned to their work unit. Cancels claims that have been worked on in their work unit. Performs data entry of claims, referrals, and Chemical Health Risk Assessment (CHRA).

Processes CMS-1500 and UB-04 claims according to the needs of the work unit and complies with the established processing and time rules. Analyzes and corrects claims reports with errors in the systems and other related programs. Analyzed claims requiring support from other departments that are processed, particularly those exceeding the assigned adjudication limit, which necessitates escalation to the next authorization level. Processes claims while maintaining the required financial and processing accuracy following current policies and procedures. Maintains and adheres to the updated personal productivity report.

Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM QUALIFICATIONS: Education and Experience: Associate’s Degree or sixty to sixty-four (60- 64) approved college credits. At least one (1) year of experience in data entry, medical billing, or a provider call center in the Healthcare Insurance Industry is preferred. OREducation and Experience: High School diploma.

At least two (2) years of experience in data entry, medical billing, or a provider call center in the Healthcare Insurance Industry is preferred. “Proven experience may be replaced by previously established requirements. ”Certifications / Licenses: N/AOther: N/ALanguages: Spanish – Intermediate (comprehensive, writing and verbal)English – Intermediate (comprehensive, writing and verbal)“Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento”