Job Brief
The Medical Claims Analyst plays a crucial role in the healthcare insurance industry by reviewing settled claims to ensure compliance with company policies and procedures. This position requires a keen eye for detail and strong analytical skills to assess payment accuracy and settlement integrity. The ideal candidate will possess a robust understanding of medical coding, healthcare regulations, and claims processing procedures, with the ability to communicate effectively with legal counsel on complex claims requiring litigation.
Responsibilities
- Review and analyze settled medical claims for accuracy and compliance with company policies.
- Investigate discrepancies in claims payments and settlements, providing detailed reports and recommendations.
- Collaborate with legal counsel on claims that require litigation or further investigation.
- Utilize industry-standard software tools for claims processing and data analysis.
- Ensure timely resolution of claims issues by coordinating with healthcare providers and insurance adjusters.
- Maintain up-to-date knowledge of healthcare regulations, medical coding guidelines, and claims processing standards.
- Prepare detailed documentation for claims audits and assist in internal compliance reviews.
- Participate in training and development initiatives to enhance skills and knowledge within the claims processing domain.
Requirements
- Bachelor’s degree in healthcare administration, business administration, or a related field preferred.
- Minimum of 2 years of experience in medical claims analysis or related healthcare positions.
- Strong understanding of medical coding (ICD, CPT, HCPCS) and healthcare reimbursement methodologies.
- Proficiency in claims processing software and Microsoft Office Suite, particularly Excel.
- Excellent analytical, problem-solving, and organizational skills.
- Effective communication skills, both written and verbal, with the ability to convey complex information clearly.
- Detail-oriented with a commitment to maintaining high standards of accuracy and compliance.
- Certifications such as Certified Medical Reimbursement Specialist (CMRS) or Certified Professional Coder (CPC) are a plus.
Similar Job Titles
- Claims Analyst
- Healthcare Claims Specialist
- Insurance Claims Examiner
- Medical Billing Analyst
- Claims Processing Specialist
- Medical Claims Reviewer
- Healthcare Reimbursement Analyst
- Claim Settlement Analyst
