[Hiring] Senior Claims Analyst @Claritev

Role Description

This role recognizes and reports new concepts for development with minimum assistance. The incumbent might be tasked to multiple clients and/or programs. They also understand the data mining process and will occasionally be tasked with training and assistance on process improvements.

• Researches new concepts for development to determine applicability to client requirements.
• Effectively utilize department tools to research concepts as appropriate, including but not limited to:
  • Client Claims Processing Policies/Systems
  • CMS/OIG/RAC Public Information
  • Provider/Member Contracts
  • State Medicaid Plans Public Information
  • Review of Adjustment Claims
• Document new concepts in an appropriate format outlined by management.
• Partner with Microsoft SQL developers to develop efficient output of concepts following the concept development process as defined by management.
• Communicate to management any issues that impact work performance and work with management to resolve them.
• Provide appropriate feedback to management on areas of improvement.
• Aid in the training and mentorship of new team members as appropriate.
• Document how to validate overpayments at a conceptual level.
• Aid in the documentation of concept approval forms for clients as necessary.
• Collaborate, coordinate, and communicate across disciplines and departments.
• Ensure compliance with HIPAA regulations and requirements.
• Demonstrate company core competencies and values.
• Due to exposure of PHI sensitive data, this role is considered a High Risk Role.
• Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.

Qualifications

• Minimum high school diploma and two (2) years' experience analyzing medical claims paid/processed data. Bachelor’s degree in a relevant field of study is strongly preferred.
• Experience on multiple claims processing platforms.
• Experience working across multiple clients with varying claims processing policies.
• Experience with various types of medical healthcare claims, including:
  • Inpatient
  • Outpatient
  • Professional
• Experience with various types of medical healthcare payment methods, including:
  • DRG
  • Per Diem
  • Outpatient Surgery Groupers
  • RUG
  • OASIS
  • Fee Schedule
• Required licensures, professional certifications, and/or board certifications as applicable.
• Ability to recognize new concepts that lead to overpayments.
• Ability to work efficiently across multiple clients.
• Experience utilizing tools to identify new concepts on data (ReThink Analyzer).
• Strong attention to detail and proven problem-solving abilities.
• Excellent written communication skills.
• Effective time management skills.
• Flexibility during times of change.
• Highly self-motivated.
• Ability to quickly apply new technologies/techniques and adapt to shifting priorities and timelines.
• Ability to work in a standard office environment, including prolonged sitting, use of monitors, and standard office equipment.
• Ability to meet physical and environmental job requirements in compliance with ADA and other employment regulations.

Requirements

• Salary range for this position is $70,000 - $80,000.
• Specific offers take into account a candidate’s education, experience and skills, as well as the candidate’s work location and internal equity.
• This position is also eligible for health insurance, 401k and bonus opportunity.

Benefits

• Medical, dental and vision coverage with low deductible & copay
• Life insurance
• Short and long-term disability
• Paid Parental Leave
• 401(k) + match
• Employee Stock Purchase Plan
• Generous Paid Time Off – accrued based on years of service
• 10 paid company holidays
• Tuition reimbursement
• Flexible Spending Account
• Employee Assistance Program
• Sick time benefits – for eligible employees, one hour of sick time for every 30 hours worked, up to a maximum accrual of 40 hours per calendar year, unless otherwise required by state law