Claims Analyst II - Fairfield

At NorthBay Health, the Claims Analyst II is responsible for independently completing all tasks in claims adjudication, including processing adjustments. The position is co-responsible for the operational functions for the organization’s capitated hospital and medical group business, processing all claims, oversees customer service issues, researching/resolving payment issues and addressing corrections in the system with the Claims Specialist. 

PRIMARY JOB RESPONSIBILITIES

1. Generates Department reports that are utilized weekly by the Claims Specialist position to track timely payment of claims.
2. Oversees the production of encounter data analysis and processing.
3. Lead point of service intake for all claims issues.
4. Claims preparation for determination of payment. Addresses corrections in the claim system and in operational processes.
5. Oversees grievances and provider dispute resolutions in partnership with the Claims Specialist position.
6. Oversees the preparation of denial letters to members.
7. Oversees the refund process and the request of refunds/overpayments from providers. Maintains claims files and other recordkeeping systems
8. Assists Senior Analyst IV and Director and other staff as requested
9. Interacts and communicates effectively inside and outside NorthBay Healthcare.
10. Oversees Managed Care claims in-service training to internal and external NorthBay providers.
11. Acts as subject expert on managed care claims payment practices.
12. Negotiates letters of agreement with non-contracted providers as requested/needed by Utilization Management.
13. Interacts with HIM, IT and outside vendors to research system issues.
14. Manages provider adds and modifications in the Managed Care billing system.
15. Provides feedback to the department management and claims staff about findings, identifying and performing needed corrective action and process improvement. 
16. Conducting audits of the claims payment system data and report results.     
17. Collaborates directly with the Managed Care team on the performance of check runs for referred claims providers.
18. Performs special claims research projects as assigned.

1. Education:  Associate’s degree required or minimum 4 years of health care claims experience.
2. Experience:  Four years of experience in claims payment systems required.  Strong experience in healthcare reimbursement mechanisms required. Experience with NorthBay’s claims payment system preferred.  Experience working on computers – Microsoft office, QuickCap and Crystal reports. 

3. Skills:  Solid knowledge of computer programs related to claims processing.  Effective writing and verbal skills; Knowledge relating to payer contracts and vendor subcontracts.  Knowledge of medical terminology.  Ability to independently prioritize work, as well as the ability to review, reprice and adjudicate claims quickly and accurately to meet deadlines. Ability to exercise appropriate independent judgment and effectively solve problems required.  Knowledge of personal computers with experience in Microsoft word, excel and crystal programs required. Ability to organize and effectively managed complex projects independently. Effective problem solving skills. Requires a high comfort level with taking initiative and responsibility, high energy and productivity, plus an orientation and ability to manage details in an organized work style.

• Ability to communicate clearly and effectively, both in listening, talking and writing. Working knowledge of DMHC guidelines regarding claims processing.
• Strong knowledge of computerized claims processing programs.
• Ability to relate cordially with co-workers, members, providers and others.  When taking calls from members or providers, the analyst is required to be able to determine the necessary action to take, such as the appropriate questions to ask, or determine the research necessary to answer questions.
• Knowledge of medical terminology.
• Knowledge of CPT, ICD-9, DRG and Revenue Codes.
• Knowledge of CMS 1500 and UB04 Forms (including POT and POS codes).
• Knowledge of Coordination of Benefits Rules.
• Ability to identify Third Party Liability Claims.
• Solid knowledge of NorthBay computerized Managed Care System, Microsoft Word, Excel and Crystal reporting.

4. Physical Effort: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  Minimal; frequent sitting and much work on a computer; occasional lifting or moving boxes/supplies, squatting, standing, walking and occasionally driving a car.

7. Hours of Work: Full-time, non-exempt.

Philip Downs