Claims Analyst

Summary:

Responsible for validating disputes presented on Explanation of Benefits (EOB), entering denied claim into the DMT database, and escalating payment /variance trends to Management and generating appeals for denied or underpaid claims.

Essential Functions:

• Validate denial reasons and ensures coding is accurate and reflects the denial reasons.  Coordinate with the Clinical Resource Center (CRC) for clinical consultations or account referrals when necessary

• Generate an appeal based on the dispute reason and contract terms specific to the payor. This includes online reconsiderations.

• Follow specific payer guidelines for appeals submission

• Escalate exhausted appeal efforts for resolution

• Work payer projects as directed

• Research contract terms/interpretation and compile necessary supporting documentation for appeals, Terms & Conditions for Internet enabled Managed Care System (IMaCS) adjudication issues, and referral to refund unit on overpayments.      

• Perform research and makes determination of corrective actions and takes appropriate steps to code the system and route account appropriately.

• Escalate denial or payment variance trends to NIC leadership team for payor escalation.