Medical Claims Analyst

Tristar Insurance Group • West Des Moines, IA

232d • $25 - $25 • Remote

About The Position

The Medical Claims Analyst position is located in Des Moines - West Des Moines, IA, and is a full-time role. The position will be office-based during the required training, which may last up to 6 months. Once training is complete, the position may become hybrid or 100% remote-based subject to company remote-work policies. Working permanently on a remote or hybrid schedule is not a guarantee for this position. Under general supervision, the Claims Analyst adjudicates claims in accordance with procedures and operations of group benefit plans. The Claims Analyst processes entry to mid-level complex claims accurately and pays health claims for medical, prescription, dental, vision, and partially self-funded benefit plans.

Requirements

• High school diploma or GED.
• Two (2) years of experience working with health claims or member and provider services in the healthcare industry, or similar.
• Highly detail oriented with excellent problem-solving skills.
• Extremely dependable and reliable; able to adapt to changes.
• Positive attitude towards work and co-workers.
• Excellent communication skills both verbal and written.
• Ability to work independently and in a team environment.
• Understanding and compliance with applicable HIPAA, Privacy, and Security policies, regulations, and laws.
• Ability to maintain composure under stressful conditions.
• Extensive working knowledge of medical terminology and medical procedures.

Responsibilities

• Process timely and accurately claims in accordance with the group plan self-funded benefit specifications for all healthcare benefits.
• Process timely and accurately claims in accordance with the Facility and Provider Network and Pharmacy Benefit Manager requirements.
• Monitor, correctly apply and appropriately use modifiers as defined in the Current Procedural Terminology (CPT) reference book.
• Have a working knowledge of ICD10 Codes, CPT Codes, HCPC Codes and ADA Codes.
• Recognize and accurately process claims for multiple services (i.e., surgeries, anesthesia, hospital [inpatient/outpatient], post-operative visits, physical therapy, office visits with or without lab or Xray services, etc.).
• Recognize and appropriately process claims submitted for services rendered using Benefit Categories as defined by the TRISTAR claims processing system.
• Process accurately out-of-network (OON) or referenced based pricing (RBP) claims as applicable.
• Understand Coordination of Benefits rules and apply coordinated benefits in the claims process.
• Identify claims that require additional information and create system letters for other Insurance, Accident inquiries, and Pre-Determinations.
• Process responses to requests for additional information and facilitate the completion of claim processing and escalation.
• Work collaboratively with the Director of Operations and team members in various departments to ensure accurate claims processing.
• Attend required company or division training, meetings, and company-sponsored activities/events when working remotely or hybrid.
• Report any system downtimes or interruptions to the supervisor.
• Obtain and maintain individual Claim Analyst licenses as required.
• Regular attendance in accordance with hours of operation are essential functions of the job.
• Perform other duties as assigned.

Benefits

• Full-time employment
• Hybrid or remote work options after training

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Insurance Carriers and Related Activities
• Education Level: High school or GED