Medical Claim AnalystPrimary Location: Phoenix, AZ
Additional Locations: AZ-Phoenix Apply
- Develop policy and procedure for medical claim cost management Analyze provider billing practices.
- Identify trends and cost saving opportunities; work with Medical/Provider Services to address provider education
- Develop and deliver training programs with regard to CPT billing appropriateness and Health Plan guidelines for claim processors
- Reviews pre-specified claims for CPT coding appropriateness and may adjudicate the claim Identify improvement opportunities and recommend workable solutions supported by cost benefit analysis
- Handles telephone and written inquiries from providers.
- Responds to all requests for reconsiderations or appeals
- Works directly with vendor to quickly review high priority claims.
- Evaluates and tests automated code review programs
- May recommend provider contract language to support medical cost management
- Apply the appropriate contractual and plan benefits to claims reviewed for $20K, pre-audit, stop loss, NAP reviews and ad-hoc negotiations
- Determines coverage, verifies eligibility, order of benefits, identifies discrepancies and applies all Medical Claim Management policies and procedures to assist in ensuring correct claim adjudication
- Works with all appropriate internal and external departments and personnel to accurately review specified claims and/or clarify medical necessity and billing appropriateness
- Assists with the development and implementation of Medical Claim Management awareness programs when required
- Accurate and timely reporting of savings results on MCRT
- Updates reporting vehicle with required information and data on a timely basis as indicated by management
- Maintains and utilizes all resource materials and systems to effectively manage job responsibilities
- 2+ years claim processing experience and demonstrated ability to handle multiple assignments competently, accurately and efficiently.
- High School Diploma or G.E.D.
- Effective communication skills, both verbal and written.Understanding of medical necessity guidelines and managed care concepts.
- Extensive knowledge of CPT, ICD9, medical terminology, and provider billing practices.
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