Claims analyst

Integrated Resources Inc.; Omaha (NE); On-site; USD 35,000 - 55,000; Full time

Job summary

A leading company in healthcare services seeks a Claims Processor in Omaha, Nebraska. In this role, you'll be responsible for reviewing and adjudicating claims, ensuring accuracy, and analyzing coverage needs. We're looking for detail-oriented individuals with strong analytical and communication skills who can thrive in a fast-paced environment.

Qualifications

• Experience in a production environment is required.
• Understanding of medical terminology is beneficial.
• Ability to maintain accuracy and production standards.

Responsibilities

• Reviews and adjudicates routine claims according to guidelines.
• Analyzes and approves routine claims that cannot be auto adjudicated.
• Coordinates responses for routine phone inquiries and written correspondence.

Skills

Analytical skills

Technical skills

Oral and written communication skills

Attention to detail

Education

High School or GED equivalent

Job description

Achieve superior claim and member service performance through an integrated process of operational, quality, medical cost, and resource management, meeting and/or exceeding member, plan sponsor, and provider expectations.

Position Summary/Mission

Reviews and adjudicates routine claims in accordance with claim processing guidelines.

Fundamental Components & Physical Requirements include but are not limited to:

1. Analyzes and approves routine claims that cannot be auto adjudicated.
2. Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
3. Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues.
4. Routes and triages complex claims to Senior Claim Benefits Specialist.
5. Proofs claim or referral submissions to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis, and pre-coding requirements.
6. May facilitate training when considered a topic subject matter expert.
7. Manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters, in accordance with prescribed operational guidelines.
8. Utilizes all applicable system functions ensuring accurate and timely claim processing, including Claim Check, reasonable and customary data, and other post-containment tools.

Performance Measures

Background/Experience Desired

Experience in a production environment.

Qualifications

Education and Certification Requirements

High School or GED equivalent.

Additional Information (situational competencies, skills, work location requirements, etc.)

• Ability to maintain accuracy and production standards.
• Analytical skills.
• Technical skills.
• Oral and written communication skills.
• Understanding of medical terminology.
• Attention to detail and accuracy.

Additional Information

All your information will be kept confidential according to EEO guidelines.