Claims Analyst/Examiner

Location

United States

Posted

70 days ago

Salary

$35 - $37 / hour

Seniority

Mid Level

No structured requirement data.

Job Description

Claims Analyst/Examiner

Advanced Medical Management

Role Description The Claims Analyst / Examiner is responsible for the accurate review, analysis, adjudication support, and investigation of professional, institutional, and ancillary claims within a Full-Risk Value-Based Care IPA/MSO environment. This role goes beyond traditional claims examination and requires strong analytical capability in payment integrity, claims variance analysis, overpayment and underpayment detection, and root-cause validation against EZCAP system configuration. - Claims Review and Examination - Review and analyze incoming claims for completeness, accuracy, eligibility, authorization requirements, coding appropriateness, and adjudication readiness. - Examine professional, institutional, outpatient, ancillary, and capitated encounter-related claims. - Investigate pended, denied, adjusted, and suspended claims. - Validate claims against member eligibility, provider status, contract terms, benefit coverage, referral/authorization requirements, and claims submission rules. - Support accurate application of payment methodology based on claim type, provider contract, fee schedule, capitation carve-out, and delegated responsibility. - Ensure claims are processed in alignment with turnaround time requirements, payment policies, and internal service standards. - Payment Integrity Analysis - Perform detailed reviews of paid claims to identify overpayments, underpayments, duplicate payments, incorrect denials, contract variances, and payment leakage. - Analyze payment outcomes for alignment with fee schedules, contracted reimbursement logic, CMS/CPT/HCPCS coding rules, modifiers, benefit plans, and delegated responsibility. - Investigate discrepancies between expected and actual payment results. - Identify trends and recurring payment issues impacting claims expense, provider abrasion, or financial leakage. - Support pre-payment and post-payment audit activities. - Partner with Finance and leadership on recoveries, offset opportunities, overpayment identification, and underpayment remediation. - Assist in development of audit logs, tracking reports, and claims issue summaries. - EZCAP Configuration Crosswalk and Root Cause Analysis - Review claims outcomes against EZCAP configuration components. - Determine whether payment issues are caused by various factors. - Escalate configuration-related findings clearly and accurately. - Participate in validation testing for configuration changes. - Help ensure contract language and delegated responsibility are translated correctly into executable EZCAP claims logic. - Claims Issue Resolution and Operational Support - Research provider disputes, claim reconsiderations, payment complaints, and escalated claims inquiries. - Prepare clear written summaries of findings, root cause, and recommended corrective action. - Work closely with various teams to resolve complex claims issues. - Support adjustment requests and reprocessing recommendations. - Assist in resolution of recurring claim errors. - Reporting and Data Analysis - Prepare recurring and ad hoc analyses of claims payment trends, error patterns, denial rates, adjustment activity, overpayment/underpayment findings, and operational pain points. - Build or support reporting that highlights financial leakage, payment variance trends, and claims adjudication opportunities. - Monitor claims metrics related to payment accuracy, pends, inventory aging, adjustment volumes, provider disputes, and denial categories. - Identify actionable trends and recommend process or configuration improvements. - Support audit readiness by maintaining documentation, case summaries, and supporting evidence. - Compliance and Regulatory Adherence - Ensure claims review activities comply with applicable health plan requirements, CMS guidance, state prompt-pay regulations, delegation requirements, and internal policies. - Maintain strict confidentiality and compliance with HIPAA and all applicable privacy and security policies. - Support accurate processing consistent with contractual obligations, regulatory standards, and audit expectations. - Participate in internal and external audit support activities. - Cross-Functional Collaboration - Partner with various teams to resolve claims and payment integrity issues. - Communicate issues with clarity. - Contribute to process improvement initiatives. - Serve as a subject matter contributor for workflows involving claims analysis, payment integrity, and configuration validation. Qualifications - Bachelor’s degree in Healthcare Administration, Business, Finance, or related field preferred. - Minimum 3–5 years of progressive experience in healthcare claims operations, claims examination, payment integrity, claims auditing, or claims analysis. - Strong experience in IPA, MSO, managed care, health plan, delegated model, or Medicare Advantage claims environments preferred. - Direct experience using EZCAP required or strongly preferred. - Demonstrated experience reviewing claims against DOFR, fee schedules, benefits, provider contracts, and authorization logic strongly preferred. - Experience identifying overpayments, underpayments, and claims payment discrepancies required. Requirements - Strong understanding of the full claims lifecycle, including intake, adjudication, denial logic, payment methodology, adjustments, and dispute resolution. - Strong knowledge of professional and institutional claims processing concepts. - Familiarity with CMS, Medicare Advantage, managed care, delegated models, and full-risk reimbursement structures. - Working knowledge of CPT / HCPCS / ICD-10 coding, modifiers, authorization and referral workflows, claims edits, provider contract reimbursement structures, fee schedules, and fee set maintenance concepts. - Strong understanding of DOFR interpretation and how financial responsibility is operationalized in claims adjudication. - Strong understanding of payment integrity principles. - Proficiency in EZCAP claims inquiry and configuration review highly preferred. - Strong experience with Excel, including filtering, pivot tables, v-lookups/x-lookups, and claims variance analysis. - Strong written and verbal communication skills. Benefits - Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan. - Wellness Made Affordable: Discounted vision and dental premiums. - Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future. - Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays. - Career Development: Tuition reimbursement to support your education and growth.

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