Claims Analyst

Trinity Health•Livonia, MI

1d•Hybrid

About The Position

The Claims Analyst analyzes and reviews claims for accuracy, completeness, and eligibility, and prepares and maintains reports and records for processing. This hybrid role is based at Trinity Health PACE Corp in Livonia, Michigan, with remote work four days per week and office work each Wednesday. The employee must live within commuting distance of the Livonia office and travel to other Trinity Health locations approximately 10% of the time. Trinity Health PACE provides comprehensive, high-quality services to seniors through an interdisciplinary team, helping them remain independent at home. The organization is guided by reverence, commitment, safety, justice, stewardship, and integrity.

Requirements

High school diploma or equivalent.
Familiarity with ICD-9-CM, ICD-10-CM, and CPT coding.
Action-oriented and customer-focused, with the ability to manage conflict and adapt to change.
Strong organizational, problem-solving, and communication skills.
Proficiency with Microsoft Office and knowledge of other relevant software.
Ability to work independently and exercise judgment.
Ability to travel to other Trinity Health locations approximately 10% of the time.
Must live within commuting distance of the Livonia office.

Nice To Haves

Bachelor's degree preferred.
1–3 years of claims, adjusting, or billing experience preferred.
Experience with Medicare reimbursement rules and CMS-1500 and UB-04 claims preferred.
Previous experience with PACE Health Plan Operation preferred.
A combination of education and experience may be acceptable.

Responsibilities

Analyze medical claims and review billing information; refer claims for further investigation when needed.
Document and investigate claims before payment, and review paid claims for accuracy.
Resolve claim discrepancies with third-party billers.
Manage fee schedules in the software system.
Communicate with interdisciplinary teams regarding unauthorized services.
Submit enrollments, disenrollments, and plan changes to CMS.
Submit data to CMS to meet reporting requirements.
Review and analyze claims loss and expense reserves established by insurance carriers.
Act as liaison between insurance carriers and the broker.
Perform pre-admission screening and concurrent reviews of patient records.
Prepare and maintain reports and records for processing.