Analyst, Operations I

• Review, investigate, and analyze claim appeals, working closely with coders to coordinate review of documentation. Assist customer service, providers, and clients on resolution of issues or inquires.
• Research and manage claim inventory for inpatient, outpatient, and provider billing using review guidance supplied by our clinical teams.
• Request and process documentation associated with special projects and clinical review inquiries.
• Access, research, and retrieve information and documentation from Claritev and one of various external client systems.
• Data Entry and database maintenance including review, validation, and maintenance of provider data.
• Perform system claim adjustments based on appeal outcomes or to process corrected claims.
• Manage manual distribution of workflow when system is unable to assign.
• Assist with special projects as assigned in conjunction with daily workload; prioritizing and shifting focus as needed
• Collaborate, coordinate, and communicate across disciplines and departments.
• Ensure compliance with HIPAA regulations and requirements.
• Demonstrate Company's Core Competencies and values held within.
• Please note: due to the exposure of PHI sensitive data, this role is considered to be a High Risk Role.
• The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.

JOB SCOPE

This position works independently under general supervision to complete the outlined job responsibilities by applying knowledge of claims and department processes. Work involves applying advanced skills using systems and tools in support of departmental operations. Duties and tasks are focused internally on high volume processes. The incumbent resolves routine questions and issues while referring more complex issues to higher levels for resolution.

JOB REQUIREMENTS (Education, Experience, And Training)

• Minimum high school diploma or GED along with two (2) years' of experience in an operations and/or service role such as claims processing, customer service, medical records, collections, data entry, or database management. Associate's degree accepted without prior experience.
• Experience in health care and/or knowledge of commonly used medical coding preferred.
• Required licensures, professional certifications, and/or Board certifications as applicable
• Communication (written, verbal and listening), analytical, organizational, prioritization, technical, etiquette and interpersonal skills
• Ability to use software and hardware peripherals related to job responsibilities including MS Office Suites with preferred proficiency with Word, Excel, and other database software.
• Ability to be flexible in quickly shifting priorities and keeping up with changes across multiple tasks in a fast paced environment while maintaining a positive and cooperative demeanor.
• Ability to demonstrate strong technical skills.
• Ability to identify issues and escalate for course of action for resolution.
• Ability to elicit trust and credibility with all levels of the organization.
• Ability to adjust/alter schedule to meet deadlines.
• Ability to work independently and handle confidential information.
• Individual in this position must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier and telephone