Claims Analyst analyzes and reviews insurance claims for accuracy, completeness, and eligibility. Reviews claims for eligibility to be reimbursed. Being a Claims Analyst maintains updated records and prepares required documentation. Assists in controlling the cost of processing claims. Additionally, Claims Analyst contacts policyholders about claims and may provide information regarding the amount of benefits. May require a bachelor's degree or its equivalent. Typically reports to a supervisor or manager. The Claims Analyst gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work. To be a Claims Analyst typically requires 2 to 4 years of related experience. (Copyright 2024 Salary.com)
POSITION SUMMARY/RESPONSIBILITIES
Analyze complex problems pertaining to claim payments, eligibility, other insurance, transplants and system issues that are beyond the scope of claim examiners and senior claim examiners that affect claims payment. Act as consultant to claims staff in complex claim issue resolution. Work cooperatively with Configuration in testing of contracts used in business operations and reporting to assure auto adjudication. Perform in accordance with company standards and policies. Promote harmonious relationships within own department, with other departments and within CFHP. Operate under limited supervision.
EDUCATION/EXPERIENCE
High school diploma or GED equivalent is required. Five years HMO/PPO claims experience required. Amisys claims processing system experience preferred. Knowledgeable of all benefit programs offered by the CFHP, Medicaid, HMO, PPO, ASO.
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