The Claims Analyst analyzes complex insurance claims issues including payments, eligibility, and system problems, providing consultation to claims staff. They collaborate with configuration teams to test contracts for business operations and auto adjudication. The role requires extensive experience in HMO/PPO claims and knowledge of various benefit programs to ensure accurate claims processing.
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 ensure 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.
claims analysis, insurance claims, HMO, PPO, claims payment, eligibility verification, auto adjudication, claims processing system, contract testing, benefit programs
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