Claims Analyst

Claims Analyst

Department: Central Business Office Reports To: Manager, Contract

FLSA: Non-Exempt

Job Purpose:

The Claims Analyst performs variance analysis to identify underpayments, files claim appeals and reconsiderations, and completes appeal follow-up for all professional and facility claims.

Primary Duties and Responsibilities:

• Assists in maintaining contract database to ensure all applicable contracts are up to date and claims are processed correctly; performs updates as necessary under the direction of the Contract Manager

• Utilizes software to identify claim variances and file appeals to insurance carriers requesting appropriate reimbursement

• Obtaining updated fee schedules from payers

• Monitors appeal status with payers timely

• Interprets payer contracts, specifically reimbursement language and methodologies

• Researches payer reimbursement policies

• Completes bundle payment allocations

• Collaborates with various departments in the CBO

Competencies:

• Service: We align our actions and decision making with the organization’s guiding platform keeping our patients at the center of all we do.

• Change Agent: We support and contribute to positive change in the organization.

• Communication and Interpersonal Relations: We communicate honestly and with compassion to build connections with our patients and each other.

• Effectiveness: We take ownership of work, doing the right thing for our customer and doing it well.

Organizational Culture:

All OrthoIllinois employees focus on service by putting the mission, vision, and value statements into practice and using the guiding principles of Compassion, Respect, Trust, Integrity, Innovation, Education Fiscal Responsibility, Practice Independence, Accountability, and Empowerment to direct their interactions and decision making. Employees promote and model the service standards to create lasting impressions, extraordinary moments, exceptional on-stage experiences, and meaningful and compassionate connections.

Education and Experience Requirements:

• High School Diploma or GED

• A minimum of two years of experience in medical claims adjudication position

• Working knowledge of Microsoft excel and Google Suites

• Knowledge of Payer websites and reimbursement methodologies preferred

Environmental/Working Conditions:

Working environment is in an office/clinic setting.

Physical/Mental Demands:

• Sit, stand, walk, stoop or kneel, crouch or crawl, and climb stairs for long periods of time

• Requires lifting, carrying and/or moving objects in a manner consistent with most office environments (generally, no more than 10 pounds on a frequent basis and 20 pounds on an occasional basis)

• Possess full range of motion in shoulders and arms, including reaching above or below the shoulder

• Finger dexterity; the ability to twist hands/wrists repetitively

• Vision (e.g., depth perception, color vision, strong vision up close), hearing (e.g., high pitch sounds, soft or distant sounds)

This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.