Health Plan Claims Analyst I- Environmental Medicine

The Health Plan Claims Analyst I is responsible for multiple components of specific health plan operations. He/she is responsible for providing administrative, operational and programmatic support services of within an assigned area/department. This position requires strong problem solving skills, analytical and organizational abilities, and involves making recommendations to program leadership for quality improvement. The position will also require coordination of workflow across multiple entities including payors, providers, and program leadership and therefore also requires effective communication

• Guides a wide range of network providers on the enrollment process for specific health plans, which includes providing education on health plan rules and claims processing process.
• Maintains provider network agreements (PNA) and communicates with patient care teams and claims team about status of PNA’s.
• Provides education to providers on Health Program rules, authorization process, documentation requirements, and clinical center review process.
• Coordinates requested medical documentation from program sponsor, ensures that documentation meets sponsored program documentation requirements and liaises between providers and medical review team.
• Reviews claims information for quality assurance purposes, makes recommendations for process improvement or changes in documentation or workflow.
• Troubleshoots incorrectly billed services and provides direct support to patient and other team members to address bills submitted by patients.
• Responds to provider inquiries regarding coverage and liaises with program sponsor/payor to bring inquiry to resolution.
• Reviews and troubleshoots medical claims payment issues.
• Reviews and approves claims for patients. Appropriately documents claim decisions (e-Claims portal).
• Works directly with the patient care team to facilitate authorization of services through the assigned area(s).
• Maintains a working knowledge of Health Programs coverage and payment guidelines, monitors changes in coverage and notifies program leadership of changes.
• Communicates outcome to care teams on resolution status of patient bills.
• Communicates outcome to providers on resolution status of provider inquiries.
• Identifies and communicates billing issues and patterns to program leadership.
• Maintains liaison with staff in other departments to coordinate program activities and training; to accomplish program objectives; and to ensure cooperative efforts are enhanced and available resources are utilized.
• Recommends new ideas and concepts for program themes, materials and resources to supplement, expand or replace existing program components.
• Other duties assigned as needed.

• Bachelor’s Degree preferred or Associates Degree with 2 years of relevant experience
• 2 years experience in medical billing or health claims, with experience in IDX billing systems in a health care or insurance environment, and familiarity with ICD/CPT coding