Claims Analyst

Summary

TurningPoint Healthcare Solutions provides clinical and technology-enabled complex condition management services that help health plans and employers improve healthcare quality, safety, and affordability. The Claims Analyst analyzes surgical claims data, reviews coding and reimbursement accuracy, supports clinical claim reviews, identifies recoupment or fraud opportunities, and manages provider and client communications in accordance with service-level and confidentiality requirements.

Responsibilities

• Analyze surgical claims data from physicians and facilities for coding and charge accuracy
• Request medical records to support additional research and review of the claim
• Process and prepare medical records for clinical review by a nurse or physician
• Review implant configurations for coding and unit accuracy
• Manage all reviews and medical record requests within timeframes per service level agreements
• Utilize client specific medical and reimbursement policies to determine appropriateness of claim and whether the procedure is covered under the members health benefit plan
• Identify and aggregate provider information for providers who are consistently submitting inaccurate and or fraudulent claims to Health Plan
• Receive and respond to telephone calls and inquiries from providers and/or Health Plan clients
• Maintain documentation on status of activity and communication of outcome
• Respect and maintain HIPAA, PHI, and company confidentiality guidelines
• Other duties as directed

Skills

• High School Diploma or equivalent is required
• Associate's or Bachelor's Degree in Healthcare or related field
• Minimum of 2 years' experience in Customer Service, or applicable healthcare operations
• 5+ years claim processing experience and demonstrated ability to handle multiple assignments competently, accurately, and efficiently
• Certification REQUIRED (One of the following): Certified Outpatient Coding (COC), (aka CPC-H) by the American Academy of Professional Coders Certified Professional Medical Auditor (CPMA), by the American Academy of Professional Coders Certified Coding Specialist (CCS), or Certified Coding Associate (CCA) by the American Health Information Management Association (AHIMA)
• Certified Coding Expertise; Knowledge of medical coding concepts and the uses of ICD10, HCPCS/CPT, and DRG coding
• Working knowledge of CMS rules, regulations, policies, and procedures
• Intermediate proficiency in Microsoft Office Suite (Excel, Outlook, PowerPoint, Word)
• Excellent communication and customer service skills and analytical and problem-solving capabilities
• Must be a highly organized, team player that is able to organize, prioritize and complete work in a timely manner despite many deadlines and competing priorities
• Working knowledge of computers, or a demonstrated technical aptitude and an ability to quickly learn new systems

Qualifications

Must Haves

• High School Diploma or equivalent is required
• Associate's or Bachelor's Degree in Healthcare or related field
• Minimum of 2 years' experience in Customer Service, or applicable healthcare operations
• 5+ years claim processing experience and demonstrated ability to handle multiple assignments competently, accurately, and efficiently
• Certification REQUIRED (One of the following): Certified Outpatient Coding (COC), (aka CPC-H) by the American Academy of Professional Coders Certified Professional Medical Auditor (CPMA), by the American Academy of Professional Coders Certified Coding Specialist (CCS), or Certified Coding Associate (CCA) by the American Health Information Management Association (AHIMA)
• Certified Coding Expertise; Knowledge of medical coding concepts and the uses of ICD10, HCPCS/CPT, and DRG coding
• Working knowledge of CMS rules, regulations, policies, and procedures
• Intermediate proficiency in Microsoft Office Suite (Excel, Outlook, PowerPoint, Word)
• Excellent communication and customer service skills and analytical and problem-solving capabilities
• Must be a highly organized, team player that is able to organize, prioritize and complete work in a timely manner despite many deadlines and competing priorities
• Working knowledge of computers, or a demonstrated technical aptitude and an ability to quickly learn new systems