Advanced Health Coordinated Care Organization · 1 day ago
Claims Analyst - Claims Processor REMOTE
Oregon, United States
Full-time
Remote
Mid Level
$18.04/hr - $24.72/hr
3+ years exp
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Responsibilities
Understand Oregon Health Plan benefits, company policies, and Plexis Quantum Choice claims payment program
Process institutional and professional claims, utilizing CMS pricer, Visium, Encoder Pro, and knowledge of payment methodologies (DRG, APC, ASC, SNF-RUG, etc)
Answer inbound calls and respond to provider inquiries about claim status and adjudication
Adjust claim payments when necessary
Apply guidelines for surgical centers, CPT codes, HCPCS, REV codes, ICD-10, NCCI Edits, National Drug Code, and other code sets
Analyze and adjudicate claims in line with Health Plan Contract and company policies
Pay, pend, or deny claims based on eligibility, referral/prior authorization, COB, medical review, and claims policy
Research and review claims that need additional data, coordinating with billing offices as required
Deliver exceptional customer service, addressing plan coverage and payment inquiries
Ensure timely response to inquiries, document interactions, and conduct necessary research
Identify and correct errors, handle overpayments, and issue refund requests
Maintain comprehensive documentation of claim decisions via phone, email, fax, and courier
Cross-train in various department functions to enhance efficiency
Participate in quality and organizational process improvement activities and teams as requested
Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
Handle confidential information and materials appropriately and maintain a secure work area
Perform other assigned duties
Participate in quality and organizational process improvement activities when requested
Support and contribute to effective safety, quality, and risk management efforts by adhering to established policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities
Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner
Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization
Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer’s expectations
Recognize new developments and remain current in care management and coordination best practice standards and anticipate organizational modifications
Advance personal knowledge base by pursuing continuing education to enhance professional competence
Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
Represent organization at meetings and conferences as applicable
Qualification
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Required
High school diploma or GED equivalent required
Knowledge of facility and professional pricing methodologies like DRG, case rate, per diem, % of billed, fee schedules, etc. is required.
Preferred
Three years of experience with healthcare claims billing or adjudication experience preferred
Experience with inpatient and outpatient facility billing (UB04/837I) preferred
Coding and billing certification strongly preferred (CPC, CPB, COC, CIC, CCS, CCA)
Will give preference to certified applicants or applicants who are currently obtaining certification.
Company
Advanced Health Coordinated Care Organization
Advanced Health is a locally owned and operated Coordinated Care Organization (CCO). We serve all communities in Coos and Curry Counties.
51-200 employees
Funding
Current Stage
Growth StageLeadership Team
Chris Hogan
Chief Financial Officer
Company data provided by crunchbase
