Analista de Reclamaciones II
Regular
Non-Exempt
GENERAL DESCRIPTION:
Analyzes claims and/or adjustments in 1500, UB04 format and member reimbursements by applying payment rules for payment adjudication and denial and /or requests for additional information, such as original claims, adjustments, COB, and grievances, from PR and non-participants including US claims applicable up to a maximum adjudication limit established in the current policy and procedure.
ESSENTIAL FUNCTIONS:
Evaluates, applies, and uses payment rules and policies in adjudicating claims and/or adjustments of claimed services in other standardized formats in the health industry.
Processes all types of original claims, adjustments, grievances, and reimbursements to members.
Refers claims and/or adjustments to areas and/or departments necessary to obtain additional information, the outreach process, and/or approvals for payment adjudication awards and/or denial.
Executes the average of claims per hour established by MCS (which may vary from time to time), maintaining financial accuracy and processing claims and/or adjustments applicable as established in the current policy and procedure.
Complies with the delivery of the productivity report every day.
Reports to their immediate supervisor any evidence of possible deficiency in the system configuration of the policyholder's coverage of the contract with the provider that may be detected during the claim adjudication process.
Notifies the immediate supervisor of any evidence of payment error or decline that may be detected during the claim adjudication process.
Communicates any evidence of possible utilization or attempted fraud that may be detected during the claim adjudication process.
Complies fully and consistently with the company's standards, policies, and procedures and the local and federal laws applicable to our industry, business, and employment practices.
May perform other duties and responsibilities as assigned in the education and experience requirements contained
MINIMUM QUALIFICATIONS:
Education and Experience:
Four-year high school diploma. Minimum three (3) years of experience as a claims analyst or in a Provider Call Center in the health insurance industry.
OR
Education and Experience:
Associate degree or 60 credits. Minimum two (2) years of experience as a claims analyst or in a Provider Call Center in the health insurance industry.
OR
Education and Experience:
Bachelor's degree. Minimum one (1) year of experience as a claims analyst or in a Provider Call Center in the health insurance industry.
"Proven experience may be replaced by previously established requirements."
Certifications/Licenses:
N/A
Other:
N/A
Languages:
Spanish –
Intermediate (writing, reading, conversational, and comprehension)
English –
Intermediate (writing, reading, conversational, and comprehension)
"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
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