Claims Analyst I

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Job description

Description:

PURPOSE:

To learn Allied's Claims Processing system, the benefit structures and basic policy provisions in the Certificates of Insurance, and Allied's procedures and philosophies to process pre-approved claims. To make appropriate decisions on the claims reviewed and convey this information through written or telephone communications with agents, insureds, providers, and other external customers. To provide support to the claims staff by making phone calls to verify the information and inputting detailed data into the computer system. These duties occur in a production environment with an emphasis on sequenced activities but with fluent decision-making.

ESSENTIAL FUNCTIONS:

• Enter data obtained from claims correspondence into the computer system, meeting departmental standards.
• Review correspondence to determine if requested information has been received.
• Make necessary modifications or corrections to the insured's claim file on the computer.
• Review and process claims within established department guidelines and standards.
• Access computer system and review policy and benefit information (i.e., Certificates of Insurance) for each claimant.
• Make appropriate contact with external sources (verbal, written letter, or electronic) to obtain the necessary information to process the claim.
• Be knowledgeable of all claims procedures, benefit structures, basic policy provisions, guidelines, state riders, telephone procedures, and equipment through initial and ongoing training.
• Process the following types of claims within established department guidelines and standards by visually reviewing the claims and applying all Policy provisions to determine if the claim is payable, if additional information is needed, or if the claim should be denied:
• Claim denials for other than pre-existing
• Claims in which initial investigation is needed
• Claims which involve writing and signing custom letters
• Claims which involve an overpayment
• UAS department referrals
• If a claim is payable, review bills for possible vendor intervention if applicable.
• If additional information is necessary, secure information via telephone call and/or written correspondence.

The position requires the ability to assess a problem and analyze the facts to reach appropriate claims decisions. Communication and interpersonal skills are necessary, as the position requires telephone contact and written correspondence with internal and external customers. The applicant must possess a positive attitude, be resilient, and adapt to a changing work environment within the department and organization.

Requirements:

• High school graduate or equivalent.
• One year of office experience.
• Medical claims processing experience is strongly preferred.
• Knowledge and understanding of medical terminology are preferred if none must complete a medical terminology course within six months.
• Ability to speak, read, comprehend and follow written and verbal English instructions. Ability to communicate effectively verbally and in writing.
• Ability to compose proper business correspondence (i.e., letters, memos, and file documentation).
• Ability to communicate in an assertive but positive manner, using excellent telephone communication skills (i.e., listening for understanding, responding accurately and professionally, and expressing self clearly and courteously).
• Demonstrated decision-making abilities
• Ability to perform basic math skills.
• Ability to operate a ten-key calculator and have experience with computers and typing at industry minimums.
• Ability to meet company attendance requirements.
• Ability to sit or stand for 7.5 hours per day.
• Ability to achieve department training standards.
• Ability to achieve and maintain department quality and production standards.
• Ability to work under and handle the stress associated with varying workloads and deadlines.
• Experience commensurate with the essential functions necessary to successfully perform the job.

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