Job details
Job type full-time
Full job description
Position summary
The sr business analyst is responsible for reviewing and responding to correspondence received from providers and for the re-adjudication of medical and hospital claims in accordance with prompt pay guidelines as well as applicable policies & proceduresIn addition, the claims correspondence coordinator must recognize, elevate and make recommendations to resolve issuesAs well as guidance and direction to the correspondence staff giving leadership and training when needed to meet departmental and corporate goals.
Requirements for all positions
All employees shall meet compliance/privacy regulations and attend at a minimum one (1) hour of compliance/privacy educational training annually, as required by independent living systems.
All employees shall meet risk management regulations and attend at the minimum one (1) hour of risk management education and training within the first thirty (30) days of employment and as required by law or independent living systems; and, for that non-physician in clinical direct care delivery services, annually thereafter.
Position responsibilities and accountability
Review, research and respond to daily correspondence received from providers via phone calls, mailed inquires and provider portal request or appeals.
Provide world class service to our providers and plan representatives by efficiently responding to written inquiries from providers and the planAddressing high level claim issues with internal departments as well as the client.
Examine and validate complaint data, calculate and adjudicate insurance claims in compliance with federal, state, and county laws, plan policy and company policies and procedures.
Adjust finalized claims for correct reimbursement, claim corrections and errors.
Analyze system to identify problems / issues as they pertain to claims processing and elevate those issues to management.
Identify issues based on provider inquiries and elevate those issues to management.
Make recommendations to drive change in an effort to improve departmental service levels.
Review quality statistics trends; coordinate efforts with the manager to implement necessary steps for improvement.
Complete projects as assigned.
Prepare management reports relative to state and compliance guidelines.
Compile statistical data; prepare reports as required.
Position qualifications
High school diploma/ged required; college course work preferred.
Minimum 5 years claims examiner or related experience, with at least 2 years claim medical data analysis responsibilities
Experience processing ub04 and cms 1500 claims
Self-starter, conscientious, independent worker.
Strong knowledge of customer service skills and techniques required.
Excellent written, verbal and grammatical communication skills required.
Ability to read, interpret, analyze technical / business procedures and / or governmental regulations required.
Ability to write reports, business correspondence and procedural manuals required.
Knowledge of automated systems (technical adeptness) required.
Demonstrated proficiency in microsoft programs (ie, excel, word, powerpoint) required; knowledge of microsoft access preferred.
Other competencies:
Ethical conduct.
Strategic-critical thinking.
Decision making.
Communications proficiency.
Presentation skills.
Travel
This position requires up to 25% travelFrequently travel is inside/outside the local area and overnight.
Telecommuting opportunity
If offered the opportunity to work remotely, the employees workdays are to be defined and adhered toAny changes to work schedule must be approved by management in advance
The work hours will be pre-determined by the manager and employee including start time, stop time and scheduled breaksIf any changes need to be made to the schedule it must be approved by the manager in advance
Employees with young children must have planned childcare during work hours
In the event of a connectivity issue, the employee will be expected to report to the office or use pto time
Productivity during telecommuting will be measuredIf management identifies productivity levels are not met, the telecommunicating opportunity will be revoked
The telecommuter will be required to occasionally report to the office for trainings, special projects, department meetings and client visits, etcThis will be deemed by the manager as appropriate and advance notice will be given to the employee
Drug free workplace
In compliance with the drug-free workplace act of 1988, independent living systems and its subsidiaries have a longstanding commitment to provide a safe, quality-oriented and productive work environmentAlcohol and drug abuse pose a threat to the health and safety of ils employees and members and to the security of the company`s equipment and facilitiesFor these reasons, ils is committed to the elimination of drug and alcohol use and abuse in the workplace.
Physical demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this jobReasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands, reach with hands and arms; talk and hearThe employee must occasionally lift and/or move up to 10 poundsSpecific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
Must be able to work in a stressful environment.
This position may require work in excess of 40 hours per week and will require some evening and weekend work hoursMust be willing to travel independently with occasional overnight travel.
Eeo statement
Independent living systems, llc, and its subsidiaries, including fcc, provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, disability, ancestry or any other characteristic protected by state, federal, or local lawReasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
