Health Services Claims Analyst

As the Health Services Claims Analyst you will play a key and collaborative role in the delivery of high quality customer service to our 200,000 plan participants in support of the 32BJ Health Fund’s mission of providing high-quality and low-cost health benefits to union members and their families.  The Health Services Claims Analyst will be responsible for 1) maintaining deep expertise about the Fund’s covered benefits 2) reviewing claims issues, ensuring claims process according to Fund’s benefit plan design 3) determining the root cause of claim issues 4) working closely with the third-party administrator to ensure issues are resolved for our plan participants

Job Responsibilities

• Evaluate claims to determine if claims were appropriate processed based on eligibility, provider contracting rules, and the Funds’ plan design. 
• Research claims and the third-party administrator’s medical management policies to understand the impact against Health Fund’s plan specifications as needed.
• Work directly with the Health Services Manager to assess and resolve claims issues presented by members and providers.
• Work directly with the Project Manager to identify and resolve plan design and member appeal-related issues.
• Work directly with the Marketing & Relationship Manager to research and resolve issues related to provider partners.
• Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management.
• Effectively organize and present findings and recommendations to leadership for decisions.
• Maintain and organize detailed information on claims issues and ensure that appropriate and comprehensive data is tracked and updated timely. 
• Track issues and monitor trends to support their resolution. 
• Improve quality, enhance workflows, identify opportunities for improvements and interdepartmental efficiencies, and develop and present recommendations for changes. 
• Collaborate with vendors and clinical partners to troubleshoot claims issues.
• Works with third-party administrator’s claims processing team to review eligibility, benefit design and system processing issues. 
• Effectively utilize the Fund’s member/employer database to research and verify member’s eligibility, benefits and communications. 

Qualifications

• Strong knowledge of claim processing policies and procedures required , including having a deep understanding of hospital/medical claims,  understanding the basics of ICD-10 coding, CPT codes, HCPCS codes, DRG coding, place of service, provider ids (TINS, NPIs), amounts paid and out of pocket costs 
• Knowledge of medical terminology, ICD/CPT coding, per diem and DRG reimbursement required 
• Ability to accurately interpret information from contractual and technical perspectives required 
• Bachelor’s Degree and 2 – 3 years’ prior related work experience in professional/facility claims or benefits/billing environment required.        Additional years of experience and/or training can be used in lieu of required educational requirements 
• Proficiency with MS Office applications (word processing, database/spreadsheet, presentation) required 
• Must be conscientious and detail oriented, recognizing unusual patterns and troubleshooting for operational improvement and efficiencies required 
• Strong analytical and problem-solving skills required 
• Ability to effectively work on multiple projects/tasks with competing priority levels required 
• Ability to effectively absorb and communicate information required 

Education

BA, BS or Associates Degree