Benefit and Claims Analyst

Highmark Health

5d•$22 - $32•Onsite

About The Position

JOB SUMMARY This job is a non-clinical resource that coordinates, analyzes, and interprets the benefits and claims processes for clinical teams and serves as a liaison between various departments across the enterprise, including but not limited to, Clinical Strategy, Sales/Client Management, Customer Service, Claims, and Medical Policy. The person in this position must fully understand all product offerings available to Organization members and be versed in claims payment methodologies, benefits administration, and business process requirements.

Requirements

3 years of customer service, health insurance benefits and claims experience.
Working knowledge of Highmark products, systems (e.g., customer service and clinical platforms, knowledge resources, etc.), operations and medical policies
PC Proficiency including Microsoft Office Products
Ability to communicate effectively in both verbal and written form with all levels of employees
Knowledge of principles and processes for providing customer service. This includes customer needs assessment, meeting quality standards for services
Knowledge of administrative and clerical procedures and systems such as managing files and records, designing forms and other office procedures
The ability to take direction, to navigate through multiple systems simultaneously
The ability to interact well with peers, supervisors and customers
Understanding the implications of new information for both current and future problem-solving and decision-making
Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate and not interrupting at inappropriate times
Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems
Ability to solve complex issues on multiple levels.
Ability to solve problems independently and creatively.
Ability to handle many tasks simultaneously and respond to customers and their issues promptly.

Nice To Haves

Working knowledge of medical procedures and terminology.
Complex claim workflow analysis and adjudication.
ICD9, CPT, HPCPS coding knowledge/experience.
Knowledge of Medicare and Medicaid policies

Responsibilities

Coordinate, analyze, and interpret the benefits and claims processes for the department.
Serve as the liaison between the department and the claims processing departments to facilitate care/case management activities and special handling claims.
Communicate benefit explanations clearly and concisely to all pertinent parties.
Investigate benefit/claim information and provide technical guidance to clinical and claims staff regarding the final adjudication of complex claims.
Research and investigate conflicting benefit structures in multi-payor situations.
Provide prompt, thorough and courteous replies to written, electronic and telephonic inquiries from internal/external customers (e.g., clinical, sales/marketing, providers, vendors, etc.)
Follow-up on all inquiries in accordance with corporate and regulatory standards and timeframes.
Must have the ability to apply knowledge about the business operations of the area within the defined scope of the job.
Assess benefit limitations in accordance with Medical Policy Guidelines.
Monitor and identify claim processing inaccuracies. Bring trends to the attention of management.
Assist with handling inbound calls and strive to resolve customer concerns received via telephone or written communication.
Work independently of support, frequently utilizing resources to resolve customer inquiries.
Collaborate with Clinical Strategy, Sales/Client Management and other areas across the enterprise to respond to client questions and concerns about care/case management and high-cost claimants.
Gather information and develop presentation/training materials for support and education.
Other duties as assigned or requested.