Claims Analyst - Medicare Advantage
Company: Bright Health
Posted on: September 24, 2022
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Our Mission is to Make Healthcare Right. Together. Built upon the
belief that by connecting and aligning the best local resources in
healthcare delivery with the financing of care, we can deliver a
superior consumer experience, lower costs, and optimized clinical
What drives our mission? The company values we live and breathe
every day. We keep it simple: Be Brave. Be Brilliant. Be
Accountable. Be Inclusive. Be Collaborative.
If you share our passion for changing healthcare so all people can
live healthy, brighter lives - apply to join our team.
SCOPE OF ROLE
The Claims Analyst assists with oversight of Medicare Advantage
claims processing, verifying information on submitted claims,
reviewing the policy to determine which charges are eligible for
reimbursement, auditing any vendor processed claims. They ensure
all business rules set by Bright Health Plan are followed by
vendors and that payments are made according to CMS guidelines,
Bright Contract and plan benefit designs. The Claims Analyst
participates in audits, coordinating with Compliance and Legal to
ensure Bright Health Plan provides all the requested data, navigate
systems as needed during audit and provide any follow up requested
The Claim Analyst job description is intended to point out major
responsibilities within the role, but it is not limited to these
- Partner with Configuration, Provider Data, Network and vendors
to ensure claims are paid to providers and members
- Monitor policies and procedures for Bright Health with
- Monitor daily reporting distributed by vendors (claim reports,
document aged reports)
- Provide recommendations on the design of claim payment system
- Serve all stakeholders through continuous monitoring and
auditing of claim processing, educational and problem-solving
- Handle adverse and politically difficult situations, as payment
accuracy has a significant impact on the financial performance of
the organization and our providers, processes related to claims
processing, managed care negotiations along with directly impacting
the financial performance of Bright Health Plan
- Read, interpret, and formulate complex computer system rules
and managed care reimbursement payment methodologies including but
not limited to CMS payment rules and requirements.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- Bachelor's degree in Business Administration or related field
required or a combination of education and below
- 3-5 years of experience in Enrollment, Premium Billing, Claims,
Member and Provider Service, and Appeals at a health insurance
company will be considered in lieu of a degree.
- 3-5 years of experience in commercial facility and professional
pricing methodologies (DRG, case rate, per diem, % of billed, fee
schedule, etc.) and application of CMS billing guidelines
- 3-5 years of health care systems and inter/intra-relationships
specific to value-based contracting activities required.
- 3-5 years of complex managed care concepts/processes, and
health insurance pricing and associated benefit design knowledge
- Intermediate or advanced Excel skills for data analysis
- Able to create and maintain strong working
- Complex problem-solving skills.
- Able to manage resources in a matrix environment, communicating
and influencing effectively at all levels of the
- Effective at vendor negotiations and relationship
- Broad knowledge of health insurance and services delivery and
- In-depth knowledge of federal, state and CMS based requirements
and the ability to develop, distribute and administer Medicare
programs in a compliant manner.
- Success managing multiple initiatives and priorities
- Able to quantify impact and ROI of initiatives.
- Experience in government programs especially Medicare
- Experience with integrating health plan support services and
other elements of operations in high-growth environment.
- Certified commercial medical billing coder a plus
- Work from home - remote
We're Making Healthcare Right. Together.
We are realizing a completely different healthcare experience where
payors, providers, doctors, and patients can all feel connected,
aligned and unified on the same team. By eradicating the frictions
of competing needs, we are making it possible to give everyone more
of what they want and deserve. We do this by:
Focusing on Consumers
We understand patient pain points, eliminating complexity while
increasing transparency, for greater access and easier
Building on Alignment
We integrate and align individual incentives at all levels, from
financing to optimization to delivery of care.
Powered by Technology
We employ our purpose built, integrated data platform to connect
clinical, financial, and social data, to deliver exceptional
As an Equal Opportunity Employer, we welcome and employ a diverse
employee group committed to meeting the needs of Bright Health, our
consumers, and the communities we serve. All qualified applicants
will receive consideration for employment without regard to race,
color, religion, sex, age, national origin, protected veteran
status, disability status, sexual orientation, gender identity or
expression, marital status, genetic information, or any other
characteristic protected by law.
Keywords: Bright Health, Minneapolis , Claims Analyst - Medicare Advantage, Professions , Minneapolis, Minnesota
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