Configuration Analyst/Claims Adjudicator

40025 -CONFIGURATION ANALYST/CLAIMS ADJUDICATOR 

DENVER, CO 80230

POSITION TYPE: W2

CONTACT DURATION: 5MONTHS + (STRONG POSSIBILITY OF EXTENSION)

DESCRIPTION: 
The Configuration Analyst/Claims Adjudicator will understand and interpret benefits, authorization and general configuration requirements to translate into Diamond configuration components, plan benefit contracts, and claims general tables that support the claim adjudication process. 

Adjudicates medical claims/bills for payment or denial within contract agreement or guidelines/protocol, using knowledge of medical claim/bill payment processing and medical regulations, verifies and updates relevant data into computerized systems and calculates manually any adjustments needed. 

ESSENTIAL FUNCTIONS: 
- Analyst will be responsible for analysis, system design and input of authorization, claims general and/plan benefit data elements in Xcelys, the host processing system, and other platform 
- Ensures the provider, authorization and benefits configuration meets established business rules and procedures. 
- Modifies the provider contract, authorization rules and benefit plan configuration as required. 
- Researches claims/bills for appropriate support documents and/or documentation. 
- Processes claims/bills as split claims when appropriate. Forwards complete claims/bills requiring additional authorization to appropriate personnel for approval or denial. Pends claims and receives pend claims for various types of research follow-up amongst other staff members. 

QUALIFICATIONS: 
. 5+ years' experience in health insurance or managed care environment 
. 5+ years' experience in claims processing/resolution 
. 2+ years of the any of following: membership, benefits, provider contracts & pricing, medical reviews, referral authorizations and code review and fee schedules 
. Demonstrated ability to research, analyze, design, plan, organize, coordinate, implement, and perform necessary follow-up and closure procedures for system related deliverables. Strong experience in documentation, research and reporting 
. Strong analytical and problem solving skills 
. Excellent interpersonal, communication, & listening skills