Responsible for initial review and triage of claims tasked for review
Determines coverage, verifies eligibility, identifies and redirects misdirects
Responsible for prepping the authorization in the system and triage cases to medical staff for review
Organized and prioritizes work to meet regulatory and claim turn-around times
Promotes communication, both internally and externally to enhance effectiveness of medical management services and health care team
Performs non-medical research and support
Adheres to Compliance with PM Policies and Regulatory Standards
Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements
Protects the confidentiality of member information and adheres to company policies regarding confidentiality
Assist in the research and resolution of claims payment issue

Effective communication, telephonic and organization skills
Familiarity with basic medical terminology and concepts used in care
Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members
Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word
2-4 years experience as a medical assistant, office assistant or claim processor
CEC/GPS, or MedCompass
High School Diploma or G.E.D

Medical Claim Analyst

Key skills