Overview
The Claims Analyst II position is responsible for organization and entry-level review of Medicare and Medicaid claims. This role handles re-pricing and calculation of overpayments for completed medical review post-pay case reviews, including any re-pricing needed for appeals. The position also supports medical review activities during fraud investigations and other program integrity initiatives by gathering information needed to complete reviews.
The role applies medical terminology and coding knowledge to re-price Medicare and Medicaid claims, manages pre-pay communication with MACs, and performs data entry, scanning, and reporting support.
This position contributes to CoventBridge Integrity Systems’ mission to help healthcare organizations reduce fraud, waste, and abuse and improve program integrity.
The Claims Analyst II reports to the Medical Review Project Manager and works from the Grove City, OH office or remotely from a home office if not local.
Responsibilities
- Maintain workflow balance to ensure re-pricing requests are completed within department time limits
- Use medical terminology and coding principles to re-price claims
- Complete assignments that meet or exceed quality assurance accuracy goals
- Implement, terminate, and track pre-pay edit requests daily
- Prepare monthly pre-pay savings reports in a timely manner
- Facilitate movement of claims to UPIC safe locations when medical records are received for pre-pay claims
- Adjudicate DME pre-pay claim decisions in VMS
- Support daily adjudication of pre-pay claims based on medical review decisions
- Scan, review, and file medical review records and other documents as needed
- Enter information into Excel spreadsheets as needed
- Attend required education and training programs
- Follow confidentiality and security guidelines for PHI and HIPAA-protected information
- Perform other duties as assigned that support UPIC goals and objectives
Requirements
- Extensive knowledge of medical terminology and coding principles
- Knowledge of Medicare and Medicaid guidelines and coverage
- Ability to read Medicare and Medicaid claims, both paper and electronic
- Basic knowledge of Medicare claims systems
- Working knowledge of Medicare and Medicaid claims pricing and payment systems
- Excellent verbal and written communication skills
- Ability to work independently with minimal supervision
- Ability to work in an MS Office environment
- High school diploma or GED required
- CPC certification preferred
- At least 1 year of experience in medical terminology and Medicare claims payment systems, or CPC certification
- Experience in the analysis and processing of Medicare and Medicaid claims
- Must have no adverse actions pending or taken against any state or federal licensing board or program
- Must have no conflict of interest as defined by the Social Security Act
Benefits
- Medical, dental, and vision plans
- Life, LTD, and STD paid by the employer
- 401(k) with company match up to 4%
- Paid time off and company-paid holidays
- Tuition assistance after 1 year of service
Location
Ohio, US
Employment Type
Full-time
Experience Level
Associate
Salary Range
$50,000 - $55,000
Remote work allowed
Yes
Posted
2 weeks ago