JOB SUMMARY: The Claims Resolutions Analyst supports the review and resolution of payment disputes including in depth research and response to project related disputes; preparing written responses to appeal and reconsideration decisions, receipt of complex sys-aid tickets, call tracking and web related inquiries. Tracking and trending of incorrect claims outcomes and work with department leaders to correct adjudication processes. The Claims Resolution Analyst will work urgent and priority requests, work in tangent with leaders to support testing and training initiatives. Additional tasks include corrected claims, retro authorizations, incorrect denial requests, and review of correspondence, reconsiderations, compliance related complaints, and provider payment appeal in a timely manner. The Claims Resolutions Analyst will utilize payment experience and problem-solving skills to determine outcomes. The Claims Resolutions Analyst will determine root causes and remediate impacted claims.

MINIMUM QUALIFICATIONS:

1. Education/Specialized Training/Licensure: High School Diploma, GED or Equivalent.

2. Work Experience (Years and Area): Five (5) years of professional and facility (inpatient/outpatient) claims payment experience or claims research, resolution or analysis of reimbursement methodologies experience.

3. Software Operated: Microsoft Office Suite

5. Other Requirements: Extensive knowledge of CMS and/or TMHP guidelines.

Claims Adjustment Analyst skills mastery; handle highest level of claim appeals and complaints; communicate with legal to secure determination; support arbitration and provider interest and penalty dispute process.

Sound analytical problem-solving and documentation skills.

Computer literate with basic knowledge of claims software usage Basic knowledge of medical procedures and terminology, medical CPT, ICD-10, DRG and Healthcare Common Procedure Coding System (HCPCS).

Ability to speak, listen and write effectively.

Quick learner with the ability to adjudicate professional and facility claims, applying appropriate reimbursement methodologies.

Ability to problem solve and work independently.

Team player with the ability to establish and maintain effective work relationships.

1. Communication Skills:
Writing /Composing (Correspondence / Reports)

2. Other Skills:
Analytical
Mathematics
Medical Terminology
Research
MS Word

3. Work Schedule: Weekdays, Flexible

RESPONSIBLE TO: Supervisor/Manager