The Claims Analyst evaluates complex claims issues related to payments, eligibility, and insurance coverage beyond the scope of standard examiners. They collaborate with claims staff and configuration teams to ensure accurate contract testing and auto adjudication. This role requires extensive experience with HMO/PPO claims and knowledge of various benefit programs including Medicaid and ASO.
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.
claims analysis, insurance claims, HMO claims, PPO claims, claims processing, benefit programs, Medicaid, contract testing, auto adjudication, claims resolution
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