Claims Analyst II

Position Purpose: Ensure timely processing of complex pending medical claims. Verify and update information on the submitted claims. Review work processes to determine reimbursement eligibility. Ensure payments and/or denials are made in accordance with company practices and procedures. Process first time claims with added complexity. Apply policy and provider contract provisions to determine if claim is payable, if additional information is needed, or if claim should be denied. Research and determine status of medical related claims. Resolve claims related to adjustments, provider calls, reconsiderations and appeals. Communicate with stakeholders’ important information needed for the successful processing of claims with added complexity. Maintain appropriate records, files, documentation, etc. Meet and maintain department production and quality standards. Performs other duties as assigned. Complies with all policies and standards. Education/Experience: High school diploma or equivalent required; Associate degree or equivalent experience preferred. 2+ years of health insurance or claims related experience required. Intermediate PC and Microsoft Office skills; basic math proficiency required. Medical coding knowledge (ICD 9/10, CPT, HCPCS) and public program claims experience preferred. Experience with Medicaid, Marketplace, or Medicare claims preferred. Required to successfully complete claims basic training, COB advanced training, and ramp period. For External Candidates: 3+