Responsible for the adjudication of complex medical/dental claims while maintaining minimum requirement for production and accuracy. Essential job functions include effectively working closely with Customer Service representatives to complete request for claims adjustments through the CSR module. Review and interpret provider issues and member reimbursements for payment. Review of Claim Check guidelines and apply guidelines to claim payment. Perform departmental research necessary for monthly leakage reconciliation received from the health plans. Conduct pre/post analysis of high dollar payments and present summary to management. Review of returned checks and perform back out process of both provider return checks and refunds received; document member history as needed. Perform post provider audits, complete all provider adjustments, and complete provider invoices received.
Job Title: Claims Appeals & Adjustment Analyst
Clinic Location: Pearland Administrative Office
Job Type: Full Time
Salary Range: $45,657 – $56,413 (Pay is based on several factors including but not limited to education, work experience, certifications, etc.)
Required: High School diploma or GED from an accredited program
Preferred: 3 month course in business school
Required: 5 years of claims adjudication experience in a HMO, PPO, or TPA environment.
Preferred: 3 years’ experience as Claims Payment Analyst with KSC and demonstrated ability to process complex medical claims.
Preferred: 10Key by touch 8,000 keystrokes
Required: Demonstrated understanding of medical terminology, CPT and ICD9 Coding and billing forms (HCFA/UB92). Demonstrate strong working knowledge of payor contracts, provider/health plan reconciliation process, and EDI reconciliation process. Able to interpret and apply contracts, fee schedules and reimbursement methods. Focus on Customer service and claims adjustments experience. Ability to understand and/or interpret regulatory guidelines (i.e. SB418, HIPAA, etc..)
Required: Self-directed and able to absorb new material quickly
Preferred: Typing (30 wpm)
Working Environment: Office
Start your career journey and become a part of a community of renowned Healthcare professionals. Kelsey-Seybold Clinic is Houston’s fastest growing, multispecialty organization with more than 40 premier locations and over 65 specialties. Our clinics are comprised of more than 600 physicians and as we continue to grow, our focus is providing quality patient care by adding to our team of clinical and non-clinical professionals that work together in a convenient, coordinated, and collaborative manner. Enjoy the rewards of a successful career while maintaining a work/life balance by joining our team today and changing the way health cares.
Why Kelsey-Seybold Clinic?
- Medical, Vision, and Dental
- Tuition Reimbursement
- Company Matching 401K
- Employee Reward and Recognition Program
- Paid time off for vacation, sick, and holidays
- Employee Assistance Program
- Continuing Medical Education allowance
Claims Appeals & Adjustment Analyst