Hunter Hamilton

Medical Billing Claims Analyst

Eden Prairie, MN
Sep 06, 2018
Oct 06, 2018
Hunter Hamilton
Job Type
Employment Status
Full Time
POSITION SUMMARY: The Claims and Operation Analyst is responsible for managing the claim adjudication process for assigned health plans.  The Claims and Operation Analyst is expected to be an expert in Medicare reimbursement rules and procedures as well as ad hoc reimbursement rates for specific plans.


Examine and enter complex claims for appropriateness and completeness of information in accordance with accepted coverage guidelines, ensuring all mandated government and state regulations are consistently met Ensures timely delivery of claims adjudication and payment to client providers Understands, communicates, and applies Medicare reimbursement rates to related claims.  Researches new reimbursement rates and Medicare fee schedule calculations as needed Analyzes industry billing and claim processing standards to understand workflow needs; communicate industry procedures and recommended actions in an effective manner Approve, pend, or deny payment according to the accepted coverage guidelines Maintaining external and internal customer relations by interacting with staff regarding claims issues. Providing service as the key contact for clients and working as directed with client providers Refers medical claims for further investigation when more information is necessary or when claims are not medically reasonable May assist in training of new groups and new staff as needed; assist the management team in problem resolution, planning and overseeing workflows; testing and preparing documentation and updating current documentation; as well as providing suggestions and recommendations to improve workflows and departmental efficiencies.  


Robust understanding of health care payment cycle; Knowledge and familiarity with health care claim forms and adjudication process Strong Medicare claim billing or adjudication knowledge Ability to speak clearly and persuasively in positive or negative situations; Listens and gets clarification; Responds well to questions Ability to perform multiple tasks simultaneously Responds promptly to customer needs; Responds to requests for service and assistance Interprets and presents numerical data effectively Ability to work both independently and with the team Ability to display enthusiasm in working with members and staff to enhance their interest and to support the goals and objectives of the department  


Associate’s degree or equivalent relevant prior work experience A minimum of 3 years’ experience with a health plan, hospital billing, or third party administrator required UB04 and 1500 claim data experience Experience pricing medical claims (facility and physicians) Experience reviewing and interpreting provider contracts and fee schedules  


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