Job Description

JOB TITLE: CLAIMS ANALYST II | CENTER OF EXCELLENCE

COMPANY OVERVIEW

Cloudmed is a first-of-its-kind, single-source enterprise platform provider of Revenue Intelligence™ solutions for hospitals. Cloudmed’s approach of combining human expertise with advanced technology utilizing machine learning algorithms provides a smarter, more predictive way for clients to realize all potential revenue. Today, Cloudmed partners with over 3,100 healthcare providers in the United States and recovers over $1.2 billion of underpaid or unidentified revenue for clients annually. Cloudmed (Triage solution) is the 2020 Revenue Integrity and Underpayment Services KLAS® Category Leader and its solution suites have HFMA Peer Review status and are HITRUST certified.

DESCRIPTION         

The Claims Analyst II has the primary role of validating and reviewing hospital accounts which are believed to have additional revenue opportunity.   Accounts with underpayments are forwarded to the Claims Analyst II who will confirm claim reimbursement, ensure there are no additional variables impacting reimbursement, diagnose the root cause of the underpayment and initiate the process of appeal with the payer. The Claims Analyst II will also assist with project planning, QA and training of Analyst Is, creation of material for Onboarding of COE staff as well as beta testing of our new proprietary company-wide platform.  RESPONSIBILITIES

• The Claims Analyst II will work within the client’s Patient Accounting system, payer portals and/or websites, and will utilize Revint Solutions’ proprietary software to research accounts in the work queue.  
• Review underpaid claims, validate calculation of the expected reimbursement, and “re-price” claims as needed.  
• Determine action required to resolve the underpayment and initiate that action, including submitting appeals and reconsideration requests. 
• Document the account to provide information and details to support resolution analyst’s pursuit for additional reimbursement. Make notes in the client’s system to indicate ‘Cloudmed’ activity. 
• Diagnose and understand how the underpayment occurred.  This will require a basic understanding of the Hospital Revenue Cycle. 
• Meet required benchmarks for accuracy and efficiency.
• Once accuracy expectations are demonstrated/met, the Claims Analyst II will work independently to manage, approve and forward their own accounts as well as assist with larger bulk and Provider Relation style issues.
• The Claims Analyst II will utilize increased knowledge of the industry, hospital revenue cycle, and payers/insurance companies to train and QA the work of Claims Analyst I.  
• Claims Analyst II is expected to understand more complex payment methodologies (OPPS, APC-based pricing, multiple OP fee schedules, AP-DRG).

REQUIRED QUALIFICATIONS

• High School graduate or Associate Degree required
• 1 – 2 years of experience with data mining, trending and auditing claims with accuracy expectations met
• Experience accessing facility/hospital patient accounting systems
• Understanding and knowledge of medical terminology, claims billing, and inpatient and outpatient coding (e.g., MSDRG, ICD-10 diagnosis and procedure codes, CPT, HCPCS, etc.)
• Experience and knowledge with inpatient and outpatient reimbursement methodologies as well as a familiarity with managed care contracts
• Strong mathematical knowledge and ability to calculate complex equations
• Must be a motivated, organized, and analytical individual with strong critical thinking skills and attention to detail
• Must be diligent in communication – verbal and written communication to give specifics and details to support claims
• Must present with strong computer skills 
• Must have a good understanding of Hospital Revenue Cycle

 DESIRED QUALIFICATIONS

• Exposure to Physician reimbursement 
• Prior experience with 835/837’s preferred
• Detail oriented and the ability to manage time efficiently, prioritize tasks and work independently as well as collaborate with a larger team
• 1+ years of experience with Revenue Integrity Applications

CULTURE FIT

• The culture at Cloudmed embraces those that demonstrate a deep passion for solving the problems of healthcare with enthusiasm for building positive working relationships and winning as a team.  Take the work seriously, but don’t take yourself too seriously.  Creating a strong workplace culture has been one of our staples, which we believe encourages and inspires employees to do their best.  Join a fulfilling team of like-minded individuals who can get their work done, but still have fun!

 BENEFITS

• Cloudmed provides an extremely competitive benefit package that includes a 401(k) match, medical/dental/vision insurance and more.

 Cloudmed is an Equal Opportunity Employer