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Suspended Claim Analyst I (Medical Management)
Exempt or Non-ExemptNon-exempt
Analyze, research, and manage claims that require medical review by interpreting applicable medical policies, benefit guidelines, regulatory guidelines, claims processing rules, and department standards.
- Associates degree and one year of related work experience; or equivalent combination of education and related work experience
- Excellent verbal and written communication skills
- Excellent customer service skills
- Good working knowledge of Microsoft Office applications
- Effectively learn multiple computer systems
Duties and Responsibilities
- 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
- Communicates case determinations in the computer system, in writing and/or by telephone; providing clear and complete information in an accurate and timely manner.
- Resolves incoming routine inquiries from members, providers, and internal departments received by telephone, correspondence, or email.
- Assists with administrative duties, such as distributing correspondence, medical records, and manually building cases in an accurate and timely manner.
- Other duties as assigned.