Research and Adjustment Analyst

Summary/Position Objectives:
Incumbent is responsible for reviewing, researching, and managing the corrective functions related to claims adjustments, refunds and special projects in support of departmental goals.

Responsibilities:
Essential Functions:
Determine reason for refund/adjustment received
Assess need of corrective measures
Complete adjustment as per department standards and policies
Identify configuration, processing and billing issues; facilitate resolution
Liaison with appropriate departments to conduct proper claims action
Develop, establish, and maintain a work priority system to ensure daily and heavy workloads are fulfilled
Maintain minimum production and quality standards

Secondary Functions:
Preserve effective working relationships with various providers, networks, and managed health care components
Maintain strict confidentiality in regards to all member, provider, and contract service information, including provider Federal Tax ID numbers, DEA numbers, and credentialing information
Maintain professionalism, including phone etiquette, manners, appearance, and attitude
Assist with claims adjudication and CI/CR phone lines as necessary
Participate in meetings as needed
Works in a manner that is not disruptive to peers, supervisors and/or subordinates.
Must maintain regular and acceptable attendance at such level as is determined in the employer’s sole discretion.
Must be available and willing to work such days and hours as the employer determines are necessary or desirable to meet its business needs.
Must be available and willing to travel to such locations and with such frequency as the employer determines is necessary or desirable to meet its business needs. (If travel required.)
REQUIREMENTS
Knowledge and Skills:
Incumbent must have exceptional oral and written communication proficiency; attention to detail and ability to multi-task; possess strong organizational skills. Capacity to establish and maintain constructive business relationships with internal/external customers while maintaining integrity and confidentiality. Aptitude to research, analyze and successfully resolve a broad spectrum of issues. Intermediate skill level with Word and Excel required. Experience in claim adjudication with an automated claim processing system. Incumbent must be a positive, professional team player, able to manage project time constraints and work with little supervision.

Education and Work Experience:
High school diploma or equivalent required. Incumbent must have three plus (3) years basic claims experience in a Managed Care Organization (MCO). One plus (1) years advanced claims processing experience, including COB/TPL, reversals, appeals, grievances, special handling, analysis, and research. Working knowledge of Medicaid, Medicare, Self-funded, and commercial insurance.

Work Environment Qualifications:
Standard office environment, required to sit for extended periods of time and key data into a PC. This position is required to work efficiently under significant time and deadline pressures. Must be able to work overtime as required.