Claims Adjustment Analyst

Internal Number: 172922

JOB SUMMARY:

The Claims Adjustment Analyst supports the review and closure of payment disputes including: corrected claims, retro authorizations, and incorrect denial requests in a timely manner. This position is responsible for processing medical claims, using industry standard practices for medical claims processing. The Claims Adjustment Analyst applies relevant rules and regulations specific to coding, providers, plan benefits, contracts, state and federal guidelines as well as Community Health Choice?s policies and procedures.

JOB SPECIFICATION:

• 30% Complete adjustment review requests
• 20% Application of established payment methodologies
• 20% Application of associated regulatory legislation.
• 20% Application of claims processing guidelines relative to contractual and non-network
• agreements using company policies and procedures
• 10% Actively contributes to achievement of departmental goals, as identified in
• Department’s annual business plan, including specific departmental process
• improvement plans. Other duties as assigned

MINIMUM QUALIFICATIONS:

Education/Specialized Training/Licensure:

• High School Diploma, GED or Equivalent.

Work Experience (Years and Area):

• One (1) year of high performance claims processing analyst experience or Two (2) years of Claims Adjustment experience.

Management Experience (Years and Area): N/A

Software Operated: Microsoft Office (Word, Excel, Outlook, etc.)

Other Requirements:
Analytical problem solving and documentations; Reimbursement methodologies; ability to adjudicate.
Ability to speak, listen and write effectively.
Team player with the ability to establish and maintain effective work relationships.

SPECIAL REQUIREMENTS: (Check Applicable Areas)

Communication Skills:
Writing /Composing (Correspondence / Reports)

Other Skills:
Analytical
Mathematics
Medical Terminology
Research
MS Word

Advanced Education: N/A

Work Schedule: Flexible, Overtime

RESPONSIBLE TO: Supervisor/Manager

EMPLOYEE SUPERVISED: N/A