Claims Analyst - LH

Luminare Health

3d•Onsite

About The Position

At Luminare Health, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development. The Claims Analyst is responsible for the accurate adjudication and processing of medical, dental, vision, or other related claims, including related correspondence and/or electronic inquiries for assigned groups. All claims and inquiries are handled according to the established plan documents, claim processing guidelines, and established total turnaround times.

Requirements

High School diploma or GED equivalent
Ability to work in a fast-paced, customer centric and production driven environment
Effective verbal and written communication skills
Ability to work effectively with team members, employees/members, providers, and clients
Ability to use common sense understanding to carry out instructions furnished in oral, written or diagram form
Flexible; open to continued process improvement
Ability to learn new/proprietary systems, to adapt to various system platforms, and to effectively use MS Excel/Word

Nice To Haves

1 year Health Insurance experience
Self-Funded Insurance/Benefits and/or TPA experience
Knowledge of medical procedure and diagnosis coding
Knowledge of medical terminology
Familiarity with Summary Plan Documents (SPDs)/Insurance Booklets or other benefit descriptive tools

Responsibilities

Review, analyze and interpret claim forms and related documents.
Determine benefit coverage based on clinical edits, plan documents/booklets, benefit reference documents, Claim Reference Manuals and claims-related memoranda, and reports.
Appropriately investigate, pend and refer claims based on claim procedures and guidelines.
Accurately handle correspondence, claims, and referrals in the established timeframes and/or performance guarantees.
Support the Claims reinsurance team, in the research and resolution of claims as assigned.
Support internal departments in the research and resolution of claims.
Communicate via telephone, email, electronic messaging, fax, or written letter with employees/members, providers of service, clients and/or other insurance carriers to ensure proper claim processing.
Other duties as needed/assigned.
Research and respond to a high volume of customer service phone calls within stated time specifications, following established department guidelines.
Ability to work with other team members in management of customer service calls.
Resolve issues through effective oral and written communication and by involving appropriate people within, or outside, the department or Company.
Effectively and professionally represent the Company in all interactions.
Provide support, training and back-up to the Claims Assistant and other team members, as needed.
Assist in establishing procedural manuals and keeping procedure documents current and up to date.