Job Summary:

__Reporting to the Director of Operations – Provider Services and Claims this individual will play a critical role in executing HealthTeam Advantage’s mission by working directly with our partners, proactively and methodically focused on ensuring the design, configuration, and adjudication of claims meets the Plan’s handling, productivity and quality standards. The Claims Analyst will work with both internal and external business partners to implement ongoing operational monitoring, and auditing, resolve service barriers, develop solutions to improve effectiveness, and identify continuous improvement initiatives to increase Claims and Benefit service levels.

**** ** Essential Duties and Responsibilities:**

• Regularly monitor the aging of claims and produce necessary inventory reports for management review
• Regularly monitor the performance of claims adjudication and production; take timely corrective action and follow-up to ensure positive outcomes
• Monitors, reviews, updates, and coordinates with TPA partner, internal team members and partner organization changes to specific coding, CMS guidance (Medicare Coverage Database, NCD/LCDs, etc.), and plan changes that may affect the Plan as it relates to Claims
• Monitor adherence to the efficiency and service level goals including volume, processing, timeliness, accuracy, and other metrics.
• Serve as a liaison between TPA/BPO partner, internal team members, and partner organization providing leadership for claims, provider disputes, direct member reimbursements, and benefit administration
• Provide guidance and support to all claims and operations personnel towards resolution of claim-related problems with an emphasis on root cause analysis and resolution of problems
• Coordinate corrective action plans with partner/client and TPA/BPO operations services administrator to resolve claims, provider disputes, and benefits issues
• Support internal plan team members with the resolution of daily issues
• Work with other departments to identify and resolve problems leading to incorrect payment of claims
• Assist management in the identification and coordination of the necessary claims, provider dispute resolution, and service training needs
• Prioritize issues identified by TPA/BPO, internal team members, and/or partner representatives and monitors progress in the resolution of the issues
• Compile, review and analyze claims management reports and take appropriate action
• Identify and advise Claims, Provider Relations, Medicare Operations and other operational areas of trends, problems, and issues as well as recommend a course of action; ensure timely communication; participate in the development and implementation of solutions
• Compose, submit, and track claim system questions and configuration requests to correct identified systemic claims payment issues
• Create and report operational tracking metrics and dashboards for monitoring claims, provider disputes, and benefits performance
• Act as project coordinator for the configuration and set up of the core claims platform, and benefit structure within the TPA/BPO system; responsible for communicating and ensuring configuration is complete and accurate.
• Confirm that all benefit components have been set up within the claims payment system and are aligned with the requirements as specified in the plan materials (i.e. evidence of coverage, summary of benefits, plan benefit packages)
• Confirm that desk-level procedures, processes, and pay policies have been finalized and are aligned with the plan requirements
• Develop deep understanding of processing capabilities and limitations of claims and benefits with TPA/BPO systems, tools, and resources; provide recommendations to meet plan requirements
• Serves on various committees and attends required meetings
• Perform other duties and projects as assigned

** Education and Experience:**

Associates Degree or equivalent of 3+ years of experience with claims processing

** Required Experience:**

3 – 5 years of experience supporting claims processing, claims system configuration, or benefit configuration functions

Experience with Medicare Advantage Plans

** Preferred:**

Bachelor’s degree in healthcare, business or healthcare related field

Certified Professional Coder (CPC)

3 – 5 years of experience within a Medicare health plan, managed care organization, or third-party administrator

Other Requirements:

Annual Flu Shot

** Knowledge, Skills and Abilities:**

** Required:** ****

Deep understanding of benefit designs, benefit structures, medical policies, and pay policies and their impact on claims / benefit configuration and claims processing

Extensive experience with operations, service and process engineering implementations

Excellent written, analytical, and oral presentation skills

Demonstrated exceptional active listening and communications skills

Advanced analytical skills

Advanced problem-solving skills

Advanced ability to work independently

Advanced ability to effectively present information and respond to questions from peers and management

** Preferred:**

Intermediate Microsoft Word, Excel, Access

Entrepreneurial mindset geared toward the creation, execution and continuous improvement of health plan operations and implementations

Physical Requirements:

****Exerting up to 10 lbs. of force occasionally (up to 1/3 of the time) and/or;

Negligible amount of force frequently (1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body

Sedimentary work involves sitting most of the time, but may involve walking or standing for brief periods of time

Jobs are sedimentary if walking and standing are required only occasionally and all other sedimentary criteria are met

** About HealthTeam Advantage**

HealthTeam Advantage is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.

HealthTeam Advantage (HTA), a Greensboro-based health insurance company, offers Medicare Advantage plans to eligible Medicare beneficiaries in 11 North Carolina counties. HTA has been named a “Best Places to Work” finalist three times by Triad Business Journal. To learn more, visit HealthTeamAdvantage.com