Non-Clinical - Claim Processer

Shift: Day - 8x5 - 09AM

Description:

As a Prepayment Fraud, Waste and Abuse Claims Analyst, you play a critical role in supporting various stakeholders through comprehensive research, issue resolution, communication management, and operational support.

Leveraging strong analytical and problem-solving skills, you investigate leads, conducting in-depth investigative research, gathering evidence, validating facts, and documenting findings.

These activities help determine whether an investigative lead warrants further action.

The role includes lead interrogation, utilizing system and program knowledge to develop accurate and timely responses.

You will serve as a trusted resource for prepayment fraud, waste, and abuse support.

Responsibilities include coordinating case handoffs to Claims and other authorized operational areas.

You will document claim actions, hold activity, releases, suspect holds, and final outcomes.

Support accurate denial processing by applying or documenting the appropriate Remittance Advice Details code for the applicable denial reason.

Verify that claim actions are completed accurately and consistently within the established workflow.

Support integration between the case-management solution and claims-processing systems when required.

Apply relevant policies, regulations, and payment guidelines accurately.

Maintain confidentiality and comply with applicable regulations.

Qualifications include excellent written, verbal, and interpersonal communication skills.

Experience collaborating with diverse audiences and cross-functional teams is essential.

You must be able to interpret policies, procedures, and regulatory requirements effectively.

Demonstrate strong organizational and time-management skills.

The ability to work in a high-paced production environment is crucial.

Proficiency with claims processing systems and Microsoft Office applications is required.

Strong collaboration skills are necessary to work effectively with various stakeholders.

Expect to work in a telework environment, requiring a broadband internet connection with adequate speed for optimal performance.

Work hours are Monday through Friday.