remote typeRemotelocationsWork From Home (HB)time typeFull timeposted onPosted Yesterdayjob requisition idR0051667

At Luminare Health , our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.

Join HCSC and be part of a purpose-driven company that will invest in your professional development.

Job Summary

This position includes a variety of claim administrative and technical tasks that support a Claim Unit and/or vendor staff, as well as the Claims Team and serves as a liaison for any internal departments.

In addition to these tasks, the Senior Claims Analyst is responsible for all of the same tasks as a Claim Analyst including the accurate adjudication and processing of medical, dental, vision, or other related claims, including related correspondence and/or electronic inquiries for assigned groups. All claims and inquiries are handled according to the established plan documents, claim processing guidelines, and established total turnaround times. Also advise team members regarding claim processing procedures.

Job Description
o Resolve client, employee/member, or provider issues regarding escalated or complex claims.
o Review and release over-authority claims up to limit specified by corporate policy.
o Handle claim referrals, including pre-determinations, using internal and external resources as needed. Advice Claim Analysts and/or vendor regarding claim processing.
o Handle network referrals as well as PPO repricing disputes.
o Review, analyze and interpret claim forms and related documents.
o Determine benefit coverage based on clinical edits, plan documents/booklets, benefit reference documents, Claim Reference Manuals and claims-related memoranda, and reports.
o Appropriately investigate, pend and refer claims based on claim procedures and guidelines.
o Accurately handle correspondence, claims, and referrals in the established timeframes and/or performance guarantees.
o Support the Claims reinsurance team, in the research and resolution of claims as assigned
o Handle complex or technical claim adjudication using internal and external resources as needed, e.g. transplants, experimental & investigational, chemotherapy, etc.
o Research and respond to vendor reconciliation requests.
o Mentor and assist with onboarding new Analysts, including the oversight of work
o Support the management, monitoring, and tracking of performance in collaboration with the Supervisor.
o Provide mentoring and coaching
o Assist Supervisor in documenting processes for analysts
o Other duties as needed/assigned

Required Job Qualifications:
o High School diploma or GED equivalent
o 3 years prior medical claim processing experience
o Ability to work in a fast-paced, customer centric & production driven environment
o Excellent verbal and written communication skills
o Ability to work effectively with employees/members, providers, clients and differing levels of co-workers including Client Managers and all levels of staff
o Demonstrated critical thinking, to carry out instructions furnished in oral, written or diagram form
o Flexible; open to continued process improvements
o Self-directed individual who works well with minimal supervision
o Good leadership, organizational and interpersonal skills
o Ability to effectively handle with complex situations and reach resolution
o Ability to analyze and interpret documents and Summary Plan Descriptions (SPDs)
o Ability to adapt to various system platforms, and to effectively use MS Excel/Word

Preferred Job Qualifications:
o Health Insurance/Third Party Administrator Experience
o High School diploma or GED equivalent

Required Job Qualifications:

• High School diploma or GED equivalent
• 3 years prior medical claim processing experience
• Ability to work in a fast-paced, customer centric & production driven environment
• Excellent verbal and written communication skills
• Ability to work effectively with employees/members, providers, clients and differing levels of co-workers including Client Managers and all levels of staff
• Demonstrated critical thinking, to carry out instructions furnished in oral, written or diagram form
• Flexible; open to continued process improvements
• Self-directed individual who works well with minimal supervision
• Good leadership, organizational and interpersonal skills
• Ability to effectively handle with complex situations and reach resolution
• Ability to analyze and interpret documents and Summary Plan Descriptions (SPDs)
• Ability to adapt to various system platforms, and to effectively use MS Excel/Word

Preferred Job Qualifications:

• Health Insurance/Third Party Administrator Experience

Location: This position may be performed remotely from anywhere within the continental United States, excluding California, New York, Alaska, and Hawaii.

Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!

EEO Statement:

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.