Senior Claims Analyst

Driscoll Health Plan; Corpus Christi (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

Driscoll Health Plan in Corpus Christi, TX is seeking a Senior Claims Analyst to perform complex claims analysis, research, and recovery work. You will collaborate with Claims Administration and health plan partners to resolve issues, lead projects, and improve processes while ensuring data integrity and compliance.

Ideal candidates have at least five years in claims analysis or medical billing with Texas Medicaid experience, plus two years in claim research and recovery.

Qualifications

• Minimum five years professional experience in claims analysis, provider medical billing, or medical coding experience with Texas Medicaid preferred.
• Minimum two years professional experience with claim research, adjustment and recover; Texas Medicaid preferred.
• Minimum High school graduate or GED required.

Responsibilities

• Analyze highly complex claims and claim issues to ensure correct claims payment and resolution with partners.
• Identify trends and recommend solutions for errors identified during claim review.
• Assist leadership to develop daily inventory plans based on resources and timelines.
• Analyze provider correspondence to determine outcomes and escalate high-priority issues.
• Lead departmental projects and operational improvement initiatives.
• Ensure data integrity, security, and process Optimizations in operations.
• Maintain privacy and confidentiality in compliance with policies.

Skills

Claims analysis

Leadership

Project coordination

Data integrity

Regulatory compliance

Mentoring/coaching

Education

High school diploma or GED

Job description

Where compassion meets innovation and technology and our employees are family.

Thank you for your interest in joining our team! Please review the job information below.

The Senior Claims Analyst will be responsible to perform highly complex and technical analysis for research, resolution and recover of health plan claims. The position is also responsible to departmental and project coordination for issues resolution and process improvement, and helps to ensure that systems, processes and reports enable the Claims Administration department to meet internal and external benchmarks. The position additionally serves as a subject matter expert regarding claims related policies and procedures.

ESSENTIAL DUTIES AND RESPONSIBILITIES: -Individuals in this position may perform and or all the below listed duties. These should be interpreted as examples of the work and are not necessarily all inclusive.

1. Analyze highly complex claims and claim issues to ensues to ensure correct claims payment, partner with Claims Administration and staff and health plan business partners for resolution.

2. Identify trends and recommend solutions for errors as identified through pre- and post-payment claim and recover review.

3. Assist with department leadership to develop daily inventory plans based on available resources, priority, and timeliness requirements.

4. Analyze provider correspondence and requests for review to determine correct outcomes and resolution, escalating high priority/risk issues to leadership.

5. Lead departmental projects and/or operational improvement initiatives.

6. Assist in the examination, assessment, and business documentation of operations and procedures to ensure data integrity, security, and process optimizations.

7. Ensure adherence to state and federal compliance, reimbursement and contract policies.

8. Provide mentoring and coaching to team members, provide assistance and feedback to less experienced staff members, and lead training efforts for new employees.

9. Openly participate in team meetings, providing ideas and suggestions to ensure departmental efficiency and quality, and to promote teamwork.

10. Maintain required compliance with privacy and confidentiality standards.

11. Maintain or exceed all established standards for performance, quality and timeliness.

12. Demonstrate business practices and personal actions that are ethical and adhere to all Health System and Health Plan policies and procedures.

13. Assist with other related work responsibilities as requested.

EDUCATION AND/OR EXPERIENCE: - Any combination of education and experience that would likely provide the required knowledge, skills, and abilities is qualifying.

Minimum five years professional experience in claims analysis, provider medical billing, or medical coding experience with Texas Medicaid preferred.

Minimum two years professional experience with Claim research, adjustment and recover; experience with Texas Medicaid preferred.

Minimum High school graduate or GED required.