Provider Claims Appeal Analyst - Benefits in Ontario, CA at Prime Healthcare

Date Posted: 10/30/2020

Job Snapshot

Job Description

Overview The Provider Claims Appeal Analyst is responsible for the complete end-to-end appeals process.  Analyst will review all written appeals, create cases from the written appeals, root cause the appeals, and will route to the appropriate teams for review.   If an appeal requires med necessity clinical review, Analyst must provide an analysis prior to submitting to UM for final determination.  Analyst’s role/responsibilities include, but not limited to; pulling in claims information from all available sources; diving and root causing appeals in order to understand if the appeal resulted from a manual claims processing error, provider error, or systemic related issues.  Analyst will be responsible for reviewing member’s eligibility and benefits in order to understand if the appeals were processed correctly.  Analyst applies deep knowledge of contract review, utilization management decisions, RX decisions, and Letter of agreements (LOAs) when analyzing appeals.  Analyst will work closely with Claims, UM/UR, Benefits, and Customer Service teams in order to collaborate on issues identified.  Analyst provides daily/ weekly/ monthly appeals reports covering all metrics within the appeal receipt.  Analyst collaborates closely with the Appeals manager in order to provide transparency of current appeals volume and projected appeals for the year.  Analyst is responsible for evaluation of billing, coding and supporting documentation of physicians, facilities and ancillary providers. Can communicate clearly and efficiently by phone, in person and email with the TPA claims administrator and other in–house staff members.  Analyst will be responsible for submitting determination resolution and acknowledgement letters back to the providers/ members.  



Responsibilities Strong knowledge of State and Federal regulations regarding the provider appeals and claims processes within the healthcare industry.
Meeting regulatory compliance per Prime’s SPDs (Summary Plan Description)
Maintaining the completeness of Prime Healthcare’s Provider Appeals Data. through Prime Healthcare’s written provider appeals processes & guidelines (e.g., creating an appeal’s case, requesting for additional provider information, submitting provider appeal’s resolution letters, SPD compliant, etc.).
Provides support to the department leaders with the creation of documents (e.g., Policy and Procedure, Job Aids, Standard Operating Procedures, etc.).
Delivers timely standing daily/weekly/monthly reports based on business needs.
Applies critical thinking in order to identify anomalies through trending reports (e.g., providers who are submitting over the 2 level maximum appeals accepted, systemic issues, internal errors, etc.)
Collaborates closely with Utilization Review, Utilization Management and Prime’s TPA.
Proactively communicates back to leadership issues that were discovered during routine root cause analysis of provider claims appeal.
Understands ERISA and Medicare Guidelines.
Understands health plan eligibility including COB, MSP, Disability, CCS, Work Comp, TPL and other primary payors.
Possesses excellent communication skills when assisting members, providers, and other team members in order to bring resolution.
Performs other duties as assigned or required.
Always maintains a professional image.

Required qualifications:

  1. Minimum of 8 years of experience in Managed Care (HMO)
  2. Minimum of 4 years of claims processing experience
  3. Minimum of 2 years of Provider claims appeal experience
  4. Full understanding of State and Federal regulations within the healthcare industry

Preferred qualifications:

  1. Utilization Management clinical experience
  2. Analytic mindset
  3. Data driven
  4. Ability to multitask
  5. Full understanding of CMS fee schedule
  6. Experiences with Provider Configuration and Member Configuration
  7. Microsoft SQL, Access, and Excel (advanced-Intermediate level)
  8. Meeting regulatory KPI (Key Performance Indicator)
  9. Compliance

We are an Equal Opportunity/Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources. EEO is the Law: