Analyst, Claims (Remote)

Tangocare; Phoenix (AZ); Remote; USD 90,000 - 135,000; Full time

Job summary

A leading healthcare company is seeking a Claims Analyst to process complex healthcare claims. This full-time remote role requires analytical expertise, knowledge of healthcare reimbursement procedures, and the ability to collaborate with providers on claims issues. Ideal candidates will have 3-5 years of experience in healthcare insurance.

Qualifications

• 3-5 years of experience in Healthcare Insurance and Claims Adjudication.
• Knowledge of Medicare/Medicaid claims processing rules and CMS regulations.
• Knowledge of coding including HIPPS, CPT and HCPCS.

Responsibilities

• Review and process insurance claims for compliance with policy terms.
• Collaborate with providers on clean claim requirements.
• Support ad-hoc reporting for claims data.

Skills

Analytical skills

Problem solving

Decision-making skills

Tools

Microsoft Excel

Microsoft Office

Job description

Brief Description

The Claims Analyst is responsible for processing complex healthcare claims in accordance with internal policies, provider contracts, and applicable regulations. This role requires analytical expertise, thorough knowledge of reimbursement procedures, and a collaborative approach to resolving claim issues and supporting provider education efforts.

Brief Description

The Claims Analyst is responsible for processing complex healthcare claims in accordance with internal policies, provider contracts, and applicable regulations. This role requires analytical expertise, thorough knowledge of reimbursement procedures, and a collaborative approach to resolving claim issues and supporting provider education efforts.

Purpose

The Claims Analyst is accountable for and oversees the following tasks:

• Reviews, processes and verification of insurance claims to ensure compliance with policy terms and regulatory requirements
• Confirm reimbursement accuracy upon claims processing per the Provider Contracts or SCA/LOA agreements on file when processing claims
• Ability to analyze claims EOP pend/denial codes and troubleshoot why claim did not pass business requirements
• Collaborate with Customer Service Analysts to educate/re-educate a network of providers on clean claim requirements
• Ability to meet Claims productivity standards (Quantity/Quality) consistently and self-sufficiently
• Support ad-hoc reporting needs including but not limited to: Auth/Claims Mismatch Files, Eligibility, Network requests for claims data etc.
• Ability to apply/retrain knowledge of coding to determine adjudication accuracy in correlation with provider contracts
• Escalate any system issues or roadblocks that prevent hitting claim metrics as applicable
• Ability to consistently meet productivity standards, quality standards and turnaround time frames as outlined for this role
  
  

Essential Job Functions And Duties

• Processing claims within the Claims Policies at 95% accuracy and meeting productivity standards as outlined
• Thorough Knowledge of EOB denial/pend codes, HIPPS, HCPCS and DX codes to process claims within regulations.
• Escalating all Provider Claim issues and systemic errors to ensure a positive rapport with our network Providers in accordance with tango Claims Policies and Procedures
• Knowledge of Medicaid EVV verification process for accurate claims processing.
• Knowledge of PDGM reimbursement processing for Medicare claims.
• Knowledge of authorization process for accurate claims processing.
• Familiarity with EDI claims/ claims submission related to CMS requirements
  
  

Required Qualifications

• 3 ~ 5 years of direct experience in Healthcare Insurance and Claims Adjudication
• In-depth knowledge of Medicare/Medicaid claims processing rules and CMS regulations
• Detailed knowledge of claims adjudication - medical coding; HIPPS, CPT and HCPCS codes
• 1-3 years in Revenue Cycle Management
• In-depth knowledge of eligibility, authorization process, skilled home health care procedures, and COB practices.
• Detailed knowledge of multiple benefit plan designs including in/out of Network designs for DSNP, MA HMO, POS, PPO etc.
  
  

Skills And Abilities

• Beginner level Microsoft Office skills (PowerPoint, Word, Outlook)
• Intermediate level Microsoft Excel skills
• Analytical, research, problem solving, and decision-making skills
• Ability to adjudicate 166+ claims a day
  
  

Job Type

• Full-time
• Remote - United States
  
  

tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Finance and Sales

• Industries

  Hospitals and Health Care

Referrals increase your chances of interviewing at tango by 2x

Get notified about new Claims Analyst jobs in Phoenix, AZ.

Phoenix, AZ $90,000.00-$135,000.00 1 week ago

Senior Actuarial Analyst III (Remote - AZ)

Senior Actuary / Principal – Medicaid & Business Development

Phoenix, AZ $164,780.00-$314,960.00 2 weeks ago

Phoenix, AZ $61,000.00-$64,000.00 3 days ago

Phoenix, AZ $61,000.00-$68,000.00 1 month ago

Phoenix, AZ $94,000.00-$108,000.00 1 day ago

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.