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Suspended Claim Analyst I (Medical Management)


Posted: 10/11/2019
Job Reference #: 5000533926606

Job Description

Employment Type


Exempt or Non-Exempt


Job Summary

Analyze, research, and manage claims that require medical review by interpreting applicable medical policies, benefit guidelines, regulatory guidelines, claims processing rules, and department standards.

Minimum Qualifications

  1. Associates degree and one year of related work experience; or equivalent combination of education and related work experience
  2. Excellent verbal and written communication skills
  3. Excellent customer service skills
  4. Good working knowledge of Microsoft Office applications
  5. Effectively learn multiple computer systems

Duties and Responsibilities

  1. Analyze, research, and manage suspended claim reviews.
    • Authorizes requests that clearly meet specified criteria according to department guidelines
    • Refers requests to Medical Directors for determination when appropriate
    • Ensures necessary medical records, previous review determinations, and other member-specific data are sufficient to make determinations
    • Requests missing information according to medical policy and benefit guidelines following department standards and regulatory statutes
    • Ensures requests are completed within regulatory guidelines and internal service level agreements
  2. Communicates case determinations in the computer system, in writing and/or by telephone; providing clear and complete information in an accurate and timely manner.
  3. Resolves incoming routine inquiries from members, providers, and internal departments received by telephone, correspondence, or email.
  4. Assists with administrative duties, such as distributing correspondence, medical records, and manually building cases in an accurate and timely manner.
  5. Other duties as assigned.