Especialista De Reportes De Reclamaciones
Regular
Exempt
GENERAL DESCRIPTION:
Supports the accuracy, compliance, and efficiency of claims operations by reviewing claims data, identifying issues and payment discrepancies, supporting reporting and testing activities, and collaborating with cross-functional teams to resolve claims-related concerns and improve operational performance.
ESSENTIAL FUNCTIONS:
- Perform User Acceptance Testing (UAT) for system enhancements, payment rule updates, Medicare policy changes, fee schedules, pricing methodologies, and provider contract configurations, ensuring accurate claim adjudication and compliance.
- Identify, investigate, and report trends, patterns, root causes, and payment discrepancies in claims processing, providing actionable recommendations for process improvement.
- Investigate duplicate payments, billing anomalies, and complex claim adjudication issues, determining root causes and implementing corrective actions to prevent recurrence.
- Monitor compliance with Medicare regulations, Center for Medicaid and Medicare Services (CMS) guidelines, payment policies, and organizational claims processing standards, identifying and escalating compliance risks when necessary.
- Develop and deliver analytical reports, audit summaries, dashboards, and presentations to support operational performance, regulatory compliance, and executive decision-making.
- Research and resolve claim file transmission, interface, and system-related issues, collaborating with Information Systems, delegated entities, and external vendors to ensure operational continuity.
- Review, validate, and correct claims data and reporting requests from Business Intelligence and other business areas, ensuring data integrity, accuracy, and completeness.
- Analyze and reconcile claims reports containing fatal and warning errors, coordinating with internal teams and delegated entities to ensure timely resolution and accurate claims processing.
- Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
- May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATIONS:
Education and Experience: Bachelor’s Degree in Business Administration, Finance, Statistics, or related fields. At least two (2) years of experience in making reports and analyzing databases, preferably in the Health Insurance Industry.
“Proven experience may be replaced by previously established requirements.”
Certifications / Licenses: Not required. Other: Knowledge of the Excel tool at the advanced level proficiency in analyzing queries in the Excel platforms (formula creation, Pivot Table, VLookup) Hyperion and Cognos.
Languages:
Spanish – Advanced (comprehensive, writing and verbal)
English – Advanced (comprehensive, writing and verbal)
“We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.”
