A Claims Analyst in the Healthcare field processes medical claims by verifying and updating information about submitted claims and reviewing the work processes required to determine reimbursement. They would be responsible for providing billing analyses of claims and applying standards of federal regulations to ensure correct billing practices.
- Application of policy and provider contract provisions to determine if a claim is payable. If additional information is needed, or if a claim should be denied.
- Determine the status of medical claims through research
- Reviewing charges, and use of payment or denial codes within established guidelines and standards
- Maintenance of records, files, and documentation
- Meet the standards of department production and quality standards
- In some cases, a High School diploma may be adequate when accompanied with the appropriate amount of related experience
- Generally though, a Bachelor’s degree in a related field is preferred
- In some cases, a current nursing certification is required
- Strong knowledge of related skills is strongly preferred. Experiences such as inpatient/outpatient hospital billing, revenue codes, and itemization of charges
- Auditing and health information management experience in a healthcare setting is preferred
- Strong proficiency in Microsoft Office, and general computer skills