Claims Analyst

TurningPoint Healthcare Solutions; Town of Florida (NY); On-site; USD 60,000 - 85,000; Full time

Job summary

TurningPoint Healthcare Solutions is seeking a Claims Analyst to analyze claims data, identify adjudication recommendations, and recoupment opportunities for Health Plan clients. The role requires attention to coding accuracy, documentation, and policy applicability.

Responsibilities include reviewing surgical claims, requesting records, and ensuring timely completion under SLAs, while maintaining HIPAA compliance and effective communication with providers and clients.

Qualifications

• High School Diploma or equivalent is required.
• Associate’s or Bachelor’s Degree in Healthcare or related field preferred.
• Minimum of 2 years’ experience in Customer Service or healthcare operations.
• 5+ years claim processing experience with multi-tasking ability.

Responsibilities

• Analyze surgical claims data from physicians and facilities for coding and charge accuracy.
• Request medical records to support additional research and review of the claim.
• Process and prepare medical records for clinical review by a nurse or physician.
• Review implant configurations for coding and unit accuracy.
• Manage all reviews and medical record requests within service level agreements.
• Utilize client-specific medical and reimbursement policies to determine claim eligibility.
• Identify and aggregate provider information for providers with inaccurate or fraudulent claims.
• Receive and respond to inquiries from providers and Health Plan clients.
• Maintain documentation on status of activity and outcomes.
• Maintain HIPAA, PHI, and confidentiality guidelines.
• Other duties as directed.

Skills

Communication skills

Customer service

Analytical skills

Problem-solving

Organizational skills

Education

High School Diploma or equivalent

Associate or Bachelor’s in Healthcare

Job description

Description

TurningPoint Healthcare Solutions is a leader in advanced clinical and technology-enabled complex condition management. TurningPoint provides an innovative suite of specialty care management services and technologies that enable health plans and employers to improve the safety, quality, and affordability of healthcare. Through its platform and specialized team of clinical experts, TurningPoint works collaboratively with providers to deliver optimal care. TurningPoint offers condition-specific, quality-driven, value-based care management services that optimize care from diagnosis and discovery through recovery. TurningPoint’s comprehensive and integrated suite of services enhances the support individuals need, at the time they need it most. Since launching in 2015, TurningPoint has provided support to more than 50 million people nationwide across numerous clinical specialties including musculoskeletal, pain management, cardiology, wound care, ear/nose/throat, and sleep. TurningPoint’s model moves beyond denial-based care to holistic condition management that improves outcomes and reduces cost. TurningPoint is an independent organization, not owned or affiliated with a health plan or provider system.

Position Summary

The Claims Analyst is responsible for the analysis of claims data to identify any potential adjudication recommendations or recoupment opportunities on behalf of the Health Plan clients.

Job Type

Full-time

Requirements

• Analyze surgical claims data from physicians and facilities for coding and charge accuracy.


• Request medical records to support additional research and review of the claim.


• Process and prepare medical records for clinical review by a nurse or physician.


• Review implant configurations for coding and unit accuracy.


• Manage all reviews and medical record requests within timeframes per service level agreements.


• Utilize client specific medical and reimbursement policies to determine appropriateness of claim and whether the procedure is covered under the members health benefit plan.


• Identify and aggregate provider information for providers who are consistently submitting inaccurate and or fraudulent claims to Health Plan.


• Receive and respond to telephone calls and inquiries from providers and/or Health Plan clients.


• Maintain documentation on status of activity and communication of outcome.


• Respect and maintain HIPAA, PHI, and company confidentiality guidelines.


• Other duties as directed.

Education, Experience and Licensure

• High School Diploma or equivalent is required. Associate’s or Bachelor’s Degree in Healthcare or related field.


• Minimum of 2 years’ experience in Customer Service, or applicable healthcare operations.


• 5+ years claim processing experience and demonstrated ability to handle multiple assignments competently, accurately, and efficiently.

Certification REQUIRED (One of the following):

• Certified Outpatient Coding (COC), (aka CPC-H) by the American Academy of Professional Coders


• Certified Professional Medical Auditor (CPMA), by the American Academy of Professional Coders


• Certified Coding Specialist (CCS), or Certified Coding Associate (CCA) by the American Health Information Management Association (AHIMA) Licensure, Certification

Knowledge and Skills

• Certified Coding Expertise; Knowledge of medical coding concepts and the uses of ICD10, HCPCS/CPT, and DRG coding.


• Working knowledge of CMS rules, regulations, policies, and procedures.


• Intermediate proficiency in Microsoft Office Suite (Excel, Outlook, PowerPoint, Word).


• Excellent communication and customer service skills and analytical and problem-solving capabilities.


• Must be a highly organized, team player that is able to organize, prioritize and complete work in a timely manner despite many deadlines and competing priorities.


• Working knowledge of computers, or a demonstrated technical aptitude and an ability to quickly learn new systems.

TurningPoint Healthcare Solutions is an Equal Opportunity Employer.