Health Claims Analyst: Adjudication & Process Improvement

Siho Holding; Columbus (IN); On-site; USD 42,000 - 62,000; Full time

Job summary

Siho Holding in Columbus, IN seeks a Claims Analyst to review, analyze, and adjudicate non-routine health claims not settled by systems. You will research plan language, determine pay or denial, and contribute to manual intervention logic and workflow automation.

This role requires strong HIPAA knowledge and ability to work in a fast-paced, detail-oriented environment. Responsibilities include reviewing medical, pharmacy, vision, and dental claims, applying benefits, ensuring timely

Qualifications

• Post-secondary education or two years experience in a claims processing environment.
• Experience in Medicare Advantage strongly preferred.
• Excellent communications (oral and written) skills.
• Intermediate skill levels in Microsoft Word, Excel, and Outlook preferred.
• Ability to work at a self-directed pace in a changing, multi-task environment.
• Detail oriented.
• Professional appearance and presence.
• Commitment to support and maintain confidentiality in conformance to HIPAA guidelines.

Responsibilities

• Review incoming medical, pharmacy vision and dental claims
• Determine and apply appropriate health plan benefits and update claims for payment
• Ensure timely and accurate claims adjudication
• Follow company guidelines and policies for adjudicating claims and responding to members
• Act as a resource for questions, opportunities, and research issues for all internal and external customers
• Responsible for meeting performance measurement standards for productivity and accuracy
• Identify and resolve operational problems using defend processes, judgment, and expertise
• Provide feedback to team members regarding process improvement opportunities
• Assist in training and mentoring of new team members
• Resolve identified claims issues based on CMS guidelines and CMS reporting
• Represent the department when needed for internal and external company meetings
• Complete special projects (including research) as assigned by Claims Supervisor or Director of Claims
• High level understanding of state and federal laws specific to health plan administration (HIPAA, ERISA, MHPAEA, ACA Mandates etc.)
• Develop and maintain statistical data as required
• Assist in departmental reporting

Skills

Excellent communication

Microsoft Word

Microsoft Excel

Microsoft Outlook

Detail oriented

Self-directed work

HIPAA compliance

Education

Post-secondary education

Two years experience in claims processing

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Siho Holding in Columbus, IN seeks a Claims Analyst to review, analyze, and adjudicate non-routine health claims not settled by systems. You will research plan language, determine pay or denial, and contribute to manual intervention logic and workflow automation.

This role requires strong HIPAA knowledge and ability to work in a fast-paced, detail-oriented environment. Responsibilities include reviewing medical, pharmacy, vision, and dental claims, applying benefits, ensuring timely