Claim Dispute & Strategy Analyst

POSITION SUMMARY :

The Claim Dispute & Strategy Analyst is responsible for researching state and payor protocols and analyzing eligible claims that receive under payment or non-payment.  This position oversees the billing vendor and process of dispute resolution, claim submission and payment requests with payors and third-party dispute resolution entities. Translate data into meaningful information and knowledge that supports decision-making or determining action that drives performance improvement and quality. Influence designated payor policy changes to impact product coverage.

PRIMARY RESPONSIBILITIES:

• Serves as a source of knowledge for the designated payor operations and performance.
• Complete position responsibilities within the appropriate time frame while adhering to quality standards.
• Translate data into meaningful information and knowledge that supports decision-making or determining action that drives performance improvement and quality.
• Influence contract negotiations with designated out-of-network payors.
• Track outcomes of payment resolutions, appeals, and negotiated claims to ensure goals are met.
• Performs analysis, identifies trends, and presents opportunities for designated payors to increase ASP and revenue.
• Participates in weekly meetings to review key metrics, workflows, trends, payor performance improvement opportunities, and strategies.
• Continuously seeks new and creative technologies that help identify and guide improvement opportunities that align with overall company success.
• Provides recommendations by performing analysis of operational, production, and other data of designated payor.
• Analyzes payor behaviors, systems, and processes to determine pathways available for advanced filings.
• Analyzes reimbursement from all sources, including carrier reimbursement and follow-up on pending claims and denial management.
• Researches complex benefits and insurance verification using various systems and portals internal and external.
• Investigate designated payors literature and agencies, and stay current on new indicators, such as state statutes and laws, and other requirements.
• Identify and escalate missing information across departments to manage the accuracy of patient records.
• Responsible for verifying patient insurance coverage, to ensure necessary procedures are covered by an individual’s provider.
• Auditing data for accuracy of patient benefit information in multiple systems and verifying existing information.
• Monitors and validates adherence to Policies and Procedures, auditing as necessary.
• Coordinates with Management to ensure a thorough understanding of trends/issues affecting payor trends.
• Develops, manages, and monitors successful completion of implementation of projects with vendors.
• Manages all aspects of the denial management for designated payors including timely and accurate advanced filing submissions and outreach for all patient authorizations, as assigned.
• Handles escalations requiring specialized and advanced reviews including state and federal arbitration entities, CMS, and the Department of Insurance.
• Partner with multiple internal cross-functional teams and successfully manage multiple product projects simultaneously.
• Establishes an ongoing working relationship with other departments impacting designated payors performance.
• Works closely with vendor operations to oversee activity that directly impacts designated payors to accurately process actions on time.
• Communicates designated payor performance in operations and methodologies to related teams and departments.
• Presents information, analysis, and updates to various levels and types of audiences.
• Communicates and cooperates with state and federal agencies to enforce statutes and laws.
• This role works with PHI on a regular basis both in paper and electronic form and utilizes various technologies to access PHI (paper and electronic) in order to perform the job.