Claims Analyst

The Health Plan (THP); Charleston (WV); On-site; USD 38,000 - 52,000; Full time

Job summary

The Health Plan is seeking a Claims Reviewer to perform initial review of HCFA 1500 and UB 04 claims under the direction of the Manager of Claims. The role emphasizes adherence to production and quality standards and following documented policies and procedures.

Key responsibilities include reviewing claim edits, ensuring timely processing, reporting patterns of incorrect billing, and maintaining a 98% quality rating while processing 15–20 claims per hour.

Qualifications

• High school diploma or equivalent required.
• Ability to follow written directions and work independently.
• Familiarity with medical terminology, CPT and ICD-10 coding is required.
• Computer and typing experience is required.

Responsibilities

• Performs initial review of all claim edits as directed. Completes or routes all reviews in accordance with time parameters established by The Health Plan.
• Reviews each claim flag in sequence, totally completing one at a time in accordance with established criteria/payment guidelines.
• Reports patterns of incorrect billing and utilization to manager or claims coordinator.
• Advises management of items that are unclear or that are not addressed in the established criteria/payment guidelines.
• Maintain a quality rating of 98%.
• Processes 15-20 claims per hour.
• Consistently displays a positive attitude and acceptable attendance.
• Participate in external and/or internal trainings as requested.

Skills

Follow written directions

Independent work

Medical terminology

CPT coding

ICD-10 coding

Computer skills

Typing

Education

High school diploma or equivalent

Job description

Under the direction of the Manager of Claims, the reviewer performs initial review of claims, including HCFA 1500 and UB 04 claims. Reviewer must meet or exceed production and quality standards and follow documented policies and procedures.

Required

• High school diploma or equivalent.
• Ability to follow written directions and work independently.
• Familiarity with medical terminology, CPT and ICD-10 coding is required.
• Computer and typing experience is required.

Desired

• Previous claims processing.
• Experience in billing or physician office experience is preferred.

Responsibilities

• Performs initial review of all claim edits as directed. Completes or routes all reviews in accordance with time parameters established by The Health Plan.
• Reviews each claim flag in sequence, totally completing one at a time in accordance with established criteria/payment guidelines.
• Reports patterns of incorrect billing and utilization to manager or claims coordinator.
• Advises management of items that are unclear or that are not addressed in the established criteria/payment guidelines.
• Maintain a quality rating of 98%.
• Processes 15-20 claims per hour.
• Consistently displays a positive attitude and acceptable attendance.
• Participate in external and/or internal trainings as requested.

Equal Opportunity Employer

The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.

8:00am - 5:00pm

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