Benefits Coding & Claim Analyst

We are looking for a Benefits Coding & Claim Analyst who will be responsible for conducting comprehensive, timely quality audits and providing audit performance data to management for department monthly statistic reporting. The audits include a full review of benefits sold to group and/or individual customers, the configuration of the benefits with our primary claim adjudication vendor, and the claim adjudication results. The quality and performance data will be utilized to monitor SLA and other contractual terms with the vendor.

Responsibilities:

• When auditing for Benefit Accuracy:
  1. Utilize internal benefit documents to validate benefits are correct and consistent among Certificate, Setup Sheets, and benefits loaded into Amerihealth's (AHA) Client Portal and Front Office System (FOS).
  2. Identify and track any internal benefit inconsistencies and report to appropriate department personnel within Sales, Account Management, Compliance and/or Enrollment teams for correction.
  3. Track AHA accuracy of benefits within FOS export, compared to benefit Setup Sheets provided to AHA. Identify and remediate errors made by AHA in the report template.
  4. Record accuracy levels on a group-by-group basis, recorded in excel and/or Salesforce tracking tool.
  5. Benefit accuracy includes all components of the group configuration, including medical, dental, vision, prescription drug, medical assistance, and other services - such as pre-certification, pre-existing condition, and accumulator reset guidelines as set forth in the certificate and setup sheet.
• When auditing for Claim Accuracy:
  1. Select claim sample for audit, and review claim adjudication for accuracy and adherence to all claim processing guidelines.
  2. Review all services are adjudicated in accordance to benefit coverage, cost share, limitations and/or plan maximums.
  3. Review appropriate application of accumulators, and accumulators that are shared between medical and prescription claims. Ensure all individual and family accumulators are properly calculated.
  4. Report on all claims reviewed, errors, and accuracy score in the report template.
• Review overall group/benefit setup inventory and report on TAT, utilizing salesforce tracking/reporting.
• Provide all accuracy and TAT SLA reporting to management monthly.
• Based on trending analysis, make recommendations relative to training opportunities for specific individuals, team, or vendor contacts.
• Follow regulations and company rules and policies as outlined in the Employee Handbook.
• Other duties as assigned.

• Undergraduate degree preferred and/or equivalent work experience.
• Minimum - five years' experience in the health insurance industry examining and adjudicating medical claims with exposure to plan features and benefits in resolving claims related issues.
• Familiarity with insurance products, standard medical policy, and insurance terminology, including CPT and ICD-10 coding.
• Ability to navigate and leverage Salesforce, benefit documents, reporting tools, and claims adjudication software for analytics and root-cause analyses.
• Excellent verbal and written communication skills and ability to effectively deal with both internal and external stakeholder complaints and concerns.
• Advanced work organization/prioritization, attention to detail, problem solving and excel/math skills.
• Ability to make decisions and support them with documentation.
• Operate standard office equipment and familiarity with Microsoft Office Products.
• Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).

• Flexibility to work in an office and/or at-home, remote office environment.
• Schedule flexibility is occasionally necessary in this position. Individual may be required to attend key business/departmental meetings and/or perform certain business critical job functions outside of normal working hours.
• Physical Demands: Must be able to communicate internally and externally through receiving and responding to auditory and visual methods.