Sr. Claims Analyst

Summary of Position

• Perform high dollar claim audits and provide oversight and guidance to claim analysts.
• Determine the root cause of errors and recommend appropriate corrective actions to prevent re-occurrence of these errors.
• Support business initiatives with quantitative transactional analysis and sample audits.
• Support business leaders with business improvement and integration projects.

Roles & Responsibilities

• Perform timely pre-payment audits of high dollar claims to verify the accuracy of claim payment and processing.
• Perform cycle time analysis to determine root cause and corrective actions.
• Perform comprehensive audits of adjustment transactions to verify that inquiries from groups, providers and members are resolved accurately and timely.
• Conduct special audits as directed by leadership.
• Provide problem definition/analysis support to the business leaders and their associated process improvements projects.
• Review and evaluate management responses and corrective action plans related to audit error findings.
• Work with leadership on disputed audit findings and make recommendations for corrective actions.
• Develop appropriate and cost-effective recommendations by partnering with Claims, Provider File Ops, Provider Network Mgmt., Utilization Mgmt. and IT to identify any required system logic modifications related to audit findings.
• Perform comprehensive reviews of new product or system implementations as requested by leadership.
• Participate in the external audit process by responding to specific audit issues or questions as directed.
• Make recommendations and modifications to the audit program desk level procedures (DLP's) based on changing business environment.
• Perform other duties as assigned, directed, or required.