Reimbursement Analyst (TELCOR / Laboratory Billing – Pre-Claim Focus)

The Health Alliance•Raleigh, NC

69d

About The Position

We are seeking a detail-oriented Reimbursement Analyst with strong experience in laboratory billing, TELCOR, SQL, and eligibility/coverage analysis. This position focuses entirely on pre-claim reimbursement readiness—ensuring claims are correct, complete, medically necessary, and compliant before submission to payers. The ideal candidate excels at problem-solving, identifying missing or invalid data, and ensuring clean, accurate claims flow through the TELCOR system and clearinghouse.

Requirements

3+ years of experience in laboratory billing, reimbursement support, or pre-claim operations.
TELCOR (RCS or QML) experience with hands-on troubleshooting and workflow understanding.
Strong problem-solving skills and the ability to diagnose complex pre-claim and data-integrity issues.
SQL proficiency for querying and validating data across RCM, LIS, and eligibility systems.
Practical experience with eligibility, benefit interpretation, coverage rules, and payer requirements.
Deep knowledge of laboratory billing inputs, including demographics, provider data, diagnosis requirements, and CPT-to-ICD medical necessity alignment.
Ability to interpret payer edit codes, clearinghouse rejection details, and claim-status acknowledgments.

Nice To Haves

Experience with HL7/EDI (especially 270/271 and 837P/835 workflows).
Familiarity with LIS-to-TELCOR integrations and data mapping.
Background in molecular, toxicology, or high-volume clinical laboratory environments.
Experience building automated data audit checks or SQL-based validation tools.

Responsibilities

Pre-Claim Readiness & Data Validation Review orders and patient data to identify missing, incomplete, or conflicting demographic, insurance, or clinical information.
Validate CPT/diagnosis alignment to ensure medical necessity requirements are met prior to claim creation.
Confirm ordering provider completeness (NPI, credentials, facility data, etc.).
Resolve coverage questions and discrepancies early to prevent downstream claim issues.
Validate patient insurance eligibility using eligibility transactions (e.g., 270/271), payer portals, or integrated tools.
Interpret benefit details, coverage limits, exclusions, and coordination of benefits issues that impact reimbursement.
Flag and resolve cases related to invalid policy numbers, inactive coverage, or mismatched patient/payer data.
Recommend front-end workflow improvements to minimize eligibility-related errors.
Review claim status responses, payer acknowledgments, and clearinghouse reports for missing data or rejections.
Analyze and resolve clearinghouse rejections, including formatting issues, coding requirements, invalid identifiers, and payer-specific edits.
Communicate with clearinghouse support teams to troubleshoot recurring edit codes or system mismatches.
Work with operations teams to validate accurate claim creation and routing.
Use TELCOR to review claims, data feed issues, file processing errors, and mapping problems that affect pre-claim integrity.
Troubleshoot TELCOR workflows including order imports, payer mapping, demographic ingestion, coverage files, and clinical data feeds.
Identify systemic issues within TELCOR that lead to recurring pre-claim rejections or missing fields.
Partner with IT, billing, and analytics teams to resolve data pipeline or interface errors.
Use SQL to investigate data inconsistencies, missing fields, eligibility mismatches, and payer configuration issues.
Query databases to identify patterns in pre-claim errors, such as recurring eligibility failures or diagnosis-related edits.
Collaborate on dashboards, reporting tools, or automated audits to strengthen pre-claim accuracy and throughput.