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J190889

Lead Claims Analyst

Helion

  • Company Helion
  • Home, PA
  • Claims
  • Full time
  • Day (United States of America)

Company :

Helion

Job Description : 

JOB SUMMARY

This job is a key member of the Helion Network Operations team that screens, reviews, evaluates, corrects errors, and/or reviews for quality control and provides final adjudication instruction of paper/electronic claims.  Determines whether to return, deny or pay claims following organizational policies and procedures. Provides direction on corrective actions needed including but not limited to processed claims, using enrollment, benefit and historical claim processing information. This job will perform post-payment reviews and advise on corrective adjustments as deemed appropriate. This role will work across the matrix to partner with key functions, including Health Plan Operations (HPO), provider contracting, provider audit, and other key implementation stakeholders, and may support multiple health plan clients.

This job is a key member of the Helion Network Operations team that screens, reviews, evaluates, corrects errors, and/or reviews for quality control and provides final adjudication instruction of paper/electronic claims.  Determines whether to return, deny or pay claims following organizational policies and procedures. Provides direction on corrective actions needed including but not limited to processed claims, using enrollment, benefit and historical claim processing information. This job will perform post-payment reviews and advise on corrective adjustments as deemed appropriate. This role will work across the matrix to partner with key functions, including Health Plan Operations (HPO), provider contracting, provider audit, and other key implementation stakeholders, and may support multiple health plan clients. . 

ESSENTIAL RESPONSIBILITIES

  • Determine if claim information submitted is accurate and complete in line with requirements for bundled payment processing. 

  • Provide processing instruction to claims adjudicator(s)

  • Provide resolution on claim rejections, review history records and determine benefit eligibility for service.

  • Review payment levels to arrive at final payment determination.

    Work with provider network to solve claim inquiries.

  • Attend all required training classes.

  • Elevate issues to next level of supervision, as appropriate.

  • Maintain accurate records, including timekeeping records.

    Other duties as assigned or requested.

EDUCATION

Minimum

  • High School Diploma/GED

Preferred

  • None

EXPERIENCE

Experience in Health Care Revenue Cycle Industry (i.e. Billing, Claims, etc.) - Provider or Payor

To Include: Business Analysis

Required

  • 5-10 years of related, progressive experience

Preferred

  • Typing speed of at least 60 words per minute

LICENSES OR CERTIFICATIONS

Required

Preferred

Experience in Health Care Revenue Cycle Industry (i.e. Billing, Claims, etc.) - Provider or Payor

To Include: Business Analysis

SKILLS

Provider Reimbursement
Microsoft Word, Excel
Oral & Written Communication Skills
Teamwork and Collaboration
Ability to take direction and to navigate through multiple systems simultaneously.
Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.
Ability to use mathematics to adjudicate claims.
Ability to solve problems within pre-defined methods and guidelines.
Knowledge of operating systems specific to claim processing.

Language

No

Travel Requirement

Yes

Position Type

Remote

Teaches / trains others regularly

Frequently

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Ocassionally

Lifting: 25 to 50 pounds

Occasionally

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. 

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf )

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.

For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

California Consumer Privacy Act Employees, Contractors, and Applicants Notice


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