Claims and Research Analyst

COMPANY OVERVIEW

Zing Health is a tech-enabled insurance company making Medicare Advantage the best it can be for those 65-and-over. Zing Health has a community-based approach that recognizes the importance of the social determinants of health in keeping individuals and communities healthy. Zing Health aims to return the physician and the member to the center of the health care equation. Members receive individualized assistance to make their transition to Zing Health as easy as possible. Zing Health offers members the ability to personalize their plans, access to facilities designed to help them better meet their healthcare needs and a dedicated care team. For more information on Zing Health, visit www.myzinghealth.com.

SUMMARY DESCRIPTION

The Claims Research Analyst role is responsible for analyzing, documenting and reporting findings of claim processing issues. Individuals in this role will interview stakeholders and research claim processing issues within the medical claims processing system and those reported through other channels such as provider disputes, member appeals and other integrated vendor services. The Analyst will use the information to document the “how” and “why” of the claim processing issues for both a detailed and summary level. The Claims Analyst must use sound business judgement and demonstrate the ability to continually prioritize tasks, as customer experience and client financials are directly influenced by their quality of work.

ESSENTIAL FUNCTIONS

• Leads implementation efforts with respect to new or modified claims processes and works with other departments to ensure proper integration with existing systems and edits.
• Ability to analyze problems, identify systemic issues, and provide recommendations mitigation and prevention.
• Supports claims editing escalated provider disputes/appeals and provides guidance across all areas of the company with regards to claims editing and proper coding, billing, and payment.
• Researches and provides feedback on claims editing performance issues, both internally and externally with providers, vendors, etc .
• Works closely with claims editing vendors on maintaining and updating edits as changes in the regulatory, legislative, or industry accepted payment policy requires .
• Collaborates with other departments to improve compliance with coding conventions and clinical practice guidelines
• Supports continuous improvement and quality initiatives to improve processes across departments.
• Thoroughly researches post payment claims and takes appropriate action to resolve identified issues within turnaround time requirements and quality standards .
• Navigates CMS and State specific websites, as well as AMA guidelines, and compare to current payment policy configuration to resolve the providers payment discrepancy .
• Working knowledge of Medicare reimbursement methodologies and rules.
• Processes claim adjustment requests following all established adjustment and claim processing guidelines.
• Identifies and escalates root cause issues to supervisor for escalated review .
• Reviews and responds to internal escalated provider disputes transferred by management and other associates.
• Acts as liaison with other departments when additional clarification is needed about claims payment policy disputes.
• Keeps Team Manager informed verbally and in writing of activities and problems within assigned area of responsibility; refers matters beyond limits of authority and expertise to Team Manager for direction.
• Performs other related duties as required or requested.
• Participates in special projects or performs duties in other areas as requested.

REQUIRED QUALIFICATIONS

Education/Experience:

Bachelor's degree in health service-related field.

Minimum 3 years experience in evaluating insurance claims in accordance with applicable contracts and government regulations within their insurance type.

Required Skills:

• Claims Investigations, Claims Processing, Research, Adjudication, Claims Resolution, Operations, Root Cause Analysis
• Communication, Time Management
• Strong knowledge in Microsoft Office applications - Word, Excel, PowerPoint and other web-based applications
• Personal management skills — Plan and manage multiple assignments and tasks, set priorities, and adapt to changing conditions and work assignments.
• Teamwork — ability to work well with one or more groups.
• Interpersonal effectiveness — Relate to co-workers and build relationships with others in the organization.
• Strong work values — Dependability, honesty, and a positive attitude.

This position offers a competitive salary and benefits, including but not limited to:

• Medical, Dental, and Vision Insurance
• Supplemental insurance (i.e., critical illness, accident, identify protection, pet)
• 401(K)
• Paid-Time-Off (accrued at 4.62 hours per pay period)
• 9 Company Holidays
• Employer paid life insurance ($50,000 flat)