Job Description

KEY COMPETENCIES

The Claims Validation Analyst manages the manual claim validation queue and is responsible for documenting results of claims performance for new/updated edits through claims review based on new or updated edit logic. This will include analysis/reporting of edit performance and root-cause research of edits that may not perform as intended. The Claims Validation Analyst supports the Claims Editing department with ad-hoc requests from other departments that involve claim validations and all tasks associated with the support of claim workflows relating to Claims Editing.  

ESSENTIAL FUNCTIONS

_ _·         Provide in-depth analysis of professional and facility claims routed to the manual claims validation queue based on new or updated edit logic.

·         Document daily claims performance for each edit and advise management of any significant performance issues immediately.

·         Work closely with Coding Specialist(s), Appeals, Implementation, PMO & Acct Mgmt at the direction of management to report on validation of claims for edits created in new edit platforms.

·         Identify and provide root-cause analysis of edit performance issues.

·         Advise management if edits are working as intended and support decision with validation data.

·         Manage relationships with Doc Retrieval, IT, and Ops Mgmt to ensure tools needed for validation (i.e., claim images) are readily available to ensure completeness of review and research.

·         Assist in creating and maintaining job aides aimed at promoting consistency in validations and claims workflow process improvements.

·         Assist in the submission of IT requests associated with validations and the enhancement of reports/tools needed to maximize results.

·         Maintain current industry knowledge of claim edit references including, but not limited to: AMA, CMS, NCCI.

·         Work closely with Associate Director of Edit Operations in departmental functions and special projects

Qualifications

• 2-5+ years of relevant experience or equivalent combination of education & work within healthcare payers/claims payment processing

·         Current certified coder (CCS, CCS-P or CPC), or Registered Health Information Technician (RHIA/RHIT) desired

• Ability to interpret claim edit rules and references
• Solid understanding of claims workflow and the ability to interpret professional and facility claim forms
• Ability to apply industry coding guidelines to claim processes
• Ability to perform audits of claims processes and apply root-cause
• Ability to manipulate data in Excel
• Experience managing business relationships
• Excellent verbal & written communication skills

Additional Information

D ISCLAIMER

 The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.