Claims Analyst II (On-Site) at Northbay

Fairfield, California, United States -

Full Time

Start Date

Immediate

Expiry Date

04 Sep, 26

Salary

40.44

Posted On

06 Jun, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Claims Adjudication, Healthcare Reimbursement, Medical Terminology, CPT, ICD-9, DRG, Revenue Codes, CMS 1500, UB04 Forms, Coordination of Benefits, Microsoft Excel, Crystal Reports, QuickCap, Problem Solving, Provider Dispute Resolution, Auditing

Industry

Hospitals and Health Care

Description

At NorthBay Health, the Claims Analyst II is responsible for independently completing all tasks in claims adjudication, including processing adjustments. The position is co-responsible for the operational functions for the organization’s capitated hospital and medical group business, processing all claims, oversees customer service issues, researching/resolving payment issues and addressing corrections in the system with the Claims Specialist. PRIMARY JOB RESPONSIBILITIES 1. Generates Department reports that are utilized weekly by the Claims Specialist position to track timely payment of claims. 2. Oversees the production of encounter data analysis and processing. 3. Lead point of service intake for all claims issues. 4. Claims preparation for determination of payment. Addresses corrections in the claim system and in operational processes. 5. Oversees grievances and provider dispute resolutions in partnership with the Claims Specialist position. 6. Oversees the preparation of denial letters to members. 7. Oversees the refund process and the request of refunds/overpayments from providers. Maintains claims files and other recordkeeping systems 8. Assists Senior Analyst IV and Director and other staff as requested 9. Interacts and communicates effectively inside and outside NorthBay Healthcare. 10. Oversees Managed Care claims in-service training to internal and external NorthBay providers. 11. Acts as subject expert on managed care claims payment practices. 12. Negotiates letters of agreement with non-contracted providers as requested/needed by Utilization Management. 13. Interacts with HIM, IT and outside vendors to research system issues. 14. Manages provider adds and modifications in the Managed Care billing system. 15. Provides feedback to the department management and claims staff about findings, identifying and performing needed corrective action and process improvement. 16. Conducting audits of the claims payment system data and report results. 17. Collaborates directly with the Managed Care team on the performance of check runs for referred claims providers. 18. Performs special claims research projects as assigned.

Responsibilities

The Claims Analyst II independently handles claims adjudication, processing adjustments, and managing operational functions for capitated hospital and medical group business. Key duties include generating reports, overseeing encounter data, resolving provider disputes, and conducting system audits.