- Review and assess insurance claims to determine validity and extent of liability.
- Analyze documentation, such as medical records, to support the investigation of claims.
- Calculate benefit payments and approve claim settlements within specified authority limits.
- Coordinate with adjusters, policyholders, claimants, and attorneys to facilitate the claims process.
- Maintain updated records and prepare required documentation for each claim.
- Utilize analytical skills to project potential losses and make recommendations to limit risk.
- Ensure adherence to Best Practice claims management and reserving of assigned indemnity and medical only claims.
- Communicate with external vendors to obtain data needed for analyses.
- Develop, maintain, and distribute historical trend analysis reports related to departmental/company performance.
- 2+ years' Experience with TPA/Healthcare claims adjudication
- Proven experience in investigation of claim pends and issue resolution, including configuration, plan design
- Experience with evaluating claim data fields for quality issues
- Strong problem-solving skills and attention to detail with the ability to work remotely in a production/quality-based program
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Construction Claims Analyst
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Multinational Claim Billing Analyst
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GeoBlue King of Prussia, United StatesWe are hiring for a Claims Audit Analyst to join the team The Claims Audit Analyst is responsible for conducting timely quality audits and for providing audit performance data to management for department monthly statistic reporting. · Responsibilities: · When auditing for Clas ...
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AVP, Analytics Program Manager
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WTW Philadelphia, United States Full timeCreate a career that goes in the direction you choose. Get to know opportunity. · The Business · In Health & Benefits (H&B), our purpose is that through our colleagues we help our clients make a difference in the lives of their employees. We help large and mid-size clients cont ...
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TPA Claims Analyst - Philadelphia, United States - Sierra Solutions Group
Description
Job SummarySierra Solutions is looking to hire multiple remote Claims Analysts with Third Party Administration experience. The ideal candidate will have 2+ years within a TPA/Employer Group with experience in analyzing and adjudicating member health claims. Ideally, Your experience includes claim adjudication, quality review, and understanding of the healthcare claims cycle. Our client's current state involves a backlog resolution and analysis of the root cause of claim pends and quality-related issues. You will play a crucial role in driving the pended claim resolution and analysis.
Primary Responsibilities
