Description : Senior Claims Analyst. Company : Trustmark. Location : Remote

Welcome to a team of caring and passionate people who work each day to meet the needs of our members and clients. At Health Benefits, you will be part of an organization committed to offering custom self-funded health benefits plans that manage costs – without compromising benefits – by offering innovative solutions, flexibility, transparency and customer support. We are now a subsidiary of Health Care Service Corporation, the largest customer-owned insurance company in the United States and a strategic partner of Health Benefits since 2018, giving us access to increased national scale and support. This is an exciting time to join our team and enhance our culture that emphasizes caring, diversity and inclusion, mutual respect, collaboration and service to our communities.

Summary: This position includes a variety of claim administrative and technical tasks that support a Claim Unit and/or outsourced vendor staff, as well as the entire Claim & Customer Service Department. The responsibilities of a Senior Claim Analyst may vary depending upon the needs of the Unit/Department.

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.

Responsibilities include:

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

Qualifications:

• Minimum three years of medical claim processing experience
• Ability to work in a fast-paced, customer service & 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
• Ability to use common sense understanding to carry out instructions furnished in oral, written or diagram form
• Flexible; open to continued process improvement
• Self-directed individual who works well with minimal supervision
• Good leadership, organizational and interpersonal skills
• Demonstrated critical thinking skills
• Ability to effectively deal with problems in varying situations and reach resolution
• Ability to read, analyze and interpret documents and Summary Plan Descriptions (SPDs)
• Ability to learn new/proprietary systems, to adapt to various system platforms, and to effectively use MS Word/Excel

Come join Health Benefits! Join a team that will not only utilize your current skills but will enhance them as well. Trustmark benefits include health/dental/vision, life insurance, FSA and HSA, 401(k) plan, Employee Assistance Program, Back-up Care for Children, Adults and Elders and many health and wellness initiatives.

If you are a Colorado or New York resident and this role is a field-based or remote role, you may be eligible to receive additional information about the compensation and benefits for this role, which we will provide upon request.

All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, sexual orientation, sexual identity, age, veteran or disability.

Required Skills

Required Experience