Claims Investigation Analyst I

geisinger; United States; Remote; USD 55,000 - 75,000; Full time

Benefits offered by this job

Healthcare benefits from day one (incl

Vision

Job summary

Geisinger, a health system based in Pennsylvania, is seeking a Regular, full-time claims specialist working from home in the United States. The role resolves complex claims issues using state and federal guidelines, coordinating with providers, internal teams and vendors to ensure accurate payments and timely communications.

You will educate providers on submission requirements, coding updates and electronic transactions, while collaborating with Account Management and customer service to

Qualifications

• Education: High School Diploma or Equivalent (GED) - (Required).
• Experience: Minimum of 4 years - Relevant experience (Required).
• Certification(s) and License(s):
• Skills: Communication, Multitasking, Organizing, Teamwork.

Responsibilities

• Acts as the technical claims expert, following state and federal guidelines and provider contracts.
• Educates providers regarding claims submission requirements, coding updates, EFT and resources such as provider manuals and fee schedules.
• Provides on-site professional guidance to facilitate issue resolution.
• Evaluates and resolves complex claim and provider billing issues in a timely manner and per standards.
• Coordinates with the provider and Account Management team on claims processing issues and follow-up with impacted parties.
• Works with customer service to ensure accurate interpretation of billing guidelines and contract terms; escalates as necessary.
• Interfaces with the call center to analyze and disseminate information from provider calls.
• Provides feedback to configuration team to ensure payment terms are set-up correctly.
• Assists with claims audits to ensure accurate payments to providers.
• Responds to provider inquiries regarding claims payments.
• Communicates with providers to gather feedback on submission practices.

Skills

Communication

Multitasking

Organizing

Teamwork

Education

High School Diploma or GED

Job description

Job Details

Location: Work from home (Pennsylvania)

Shift: Days (United States of America)

Scheduled Weekly Hours: 40

Worker Type: Regular

Exemption Status: No

Job Summary

Reviews and resolves complex claims issues, using established state and federal guidelines, departmental policies and procedures to ensure that work is performed accurately and delivered to meet set objectives. Acts as a liaison between the provider and other Health Plan departments and facilitates the exchange of information between the grievances, claims processing and provider relations systems. Follows up with providers, internal and external vendors to ensure resolution is communicated to impacted parties.

Job Duties

• Acts as the technical claims expert, following state and federal guidelines and provider contracts.
• Educates contracted and non-contracted providers regarding appropriate claims submission requirements, coding updates, electronic claims transactions and electronic fund transfer and available resources such as provider manuals, websites, fee schedules, etc.
• Provides on-site professional guidance as needed to facilitate issue resolution.
• Evaluates and resolves complex claim and provider billing issues in a timely manner and according to set standards.
• Coordinates with the provider, as needed, in alignment with the Account Management team, on claims processing issues and provides follow-up to all impacted parties.
• Works with the customer service team to ensure accurate interpretation of billing guidelines, member benefits, contract terms, exclusions and limitations; escalates as necessary.
• Interfaces with the call center to compile, analyze and disseminate information from provider calls.
• Provides feedback to the configuration team to ensure payment terms are set-up correctly.
• Assists with completion of claims audits to ensure accurate payments to providers.
• Responds to provider inquiries regarding claims payments.
• Communicates with providers to gain feedback regarding the extent to which providers are informed about appropriate claims submission practices.
• Provides information and facilitates and coordinates appropriate resolution of issues and complaints.
• Documents inquires, complaints and other data in all applicable systems in an accurate, clear and timely manner.
• Identifies trends and develops ways to streamline and simplify internal processes as necessary to reduce turnaround times and improve data quality and provider satisfaction.
• Initiates process improvement projects resulting from operational concerns.

Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

*Relevant experience may be a combination of related work experience and degree obtained (Associate's Degree = 2 years; Bachelor's Degree = 4 years).

Position Details

Education: High School Diploma or Equivalent (GED)- (Required)

Experience: Minimum of 4 years-Relevant experience* (Required)

Certification(s) and License(s):

Skills: Communication, Multitasking, Organizing, Teamwork

OUR PURPOSE & VALUES

Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities.

KINDNESS: We strive to treat everyone as we would hope to be treated ourselves.

EXCELLENCE: We treasure colleagues who humbly strive for excellence.

LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow.

INNOVATION : We constantly seek new and better ways to care for our patients, our members, our community, and the nation.

SAFETY: We provide a safe environment for our patients and members and the Geisinger family.

We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, we encourage an atmosphere of collaboration, cooperation and collegiality.

Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.