Claims Analyst (Hybrid) - Coastal TPA Job Listing at Montage Health in Monterey, CA (Job ID 28448144)

Description

Welcome to Montage Health's application process!

Job Description:

The Claims Analyst is responsible for processing and analyzing health insurance claims, reviewing eligibility, interpreting and applying plan requirements and responding to claim inquiries from both internal and external stakeholders.

• Process medical, dental, and vision claims accurately and within contractual turnaround times.

• Code medical procedures, diagnoses and supplies.

• Coordinate benefits with other group health plans.

• Interpret plan documents and apply plan benefits based on that interpretation.

• Verify eligibility and authorization.

• Assist Customer Service with benefit clarification.

• Refer appropriate claims, pre-certifications and appeals to management and/or medical review.

• Request necessary documentation from providers and/or insureds.

• Assist in the investigation of possible fraudulent claims.

• Investigate injury cases for potential third-party or workers' compensation liability.

• Process appeals and grievances in coordination with the Claims Supervisor.

• Request claim recoupments/refunds from providers/members, as required.

• Weekly reporting of high dollar claims.

• Perform other duties and functions as assigned.

Position Requirements

• Excellent verbal and written communication skills, including active listening.

• Ability to manage multiple priorities and meet deadlines.

• Working knowledge of coding, billing and medical terminology.

• Ability to operate spreadsheet, word processing programs and computer equipment required to fulfill position responsibilities.

• Working knowledge of federal regulation specific to the administration of self-funded employer health and welfare plans, including ERISA, Department of Labor and Health and Human Services.

• Ability to work with minimal supervision.

• Readily adaptable to the changing needs of the business; able to manage multiple priorities; tolerance for ambiguity.

• Ability to use sound judgement, identify next steps to be taken, and develop appropriate solutions.

• Ability to collaborate with multiple parties to solve problems.

Competencies

• Accountability and Dependability: Assumes responsibility for accomplishing duties in an effective and timely manner.

• Integrity:  Consistently honors commitments and takes responsibility for actions and words.

• Software and Computer Skills: Proficient in the use of Microsoft Office Suite, Highly skilled at using the Internet. Must learn effectively with computer-based and/or online training.

• Flexibility:  Demonstrates adaptability and openness to alternative solutions and flexibility when interacting with others, understanding their attitudes, needs, interests, and perspectives.

• Inclusiveness:  The ability to network and partner with all internal and external stakeholders including broad and diverse representation of private/public and traditional/non-traditional community organizations.

Skills and Education

• Associates degree, or applicable professional experience, required

• Minimum 1 to 3 years experience in a healthcare or insurance industry setting.

Benefits              Competitive benefit package

Salary                   $25 per hour

Aspire Health Plan is an equal opportunity employer.

Assigned Work Hours:

M-F, 8am-5pm

Hybrid schedule. On-site one week a quarter, or as otherwise dictated by business needs.

Position Type:

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