Health Business Solutions LLC

Claims Analyst

JOB OVERVIEW:

The Claims Analyst is responsible for analyzing, appealing, and resolving denied or underpaid medical insurance claims to ensure accurate reimbursement for healthcare services. This role requires a deep understanding of payer requirements, billing codes, and denial management processes to identify root causes and prevent future denials.

JOB DUTIES:

• Review and research denied or underpaid claims from insurance carriers, identifying denial trends and root causes.
• Prepare and submit timely and accurate appeals with supporting medical documentation and payer guidelines.
• Communicate effectively with insurance companies to follow up on outstanding denials and appeal status.
• Collaborate with billing, coding, and client account teams to resolve discrepancies and ensure claim accuracy.
• Update claim activity notes in the system and maintain detailed documentation of actions taken.
• Identify patterns or systemic issues contributing to denials and report findings to leadership for process improvement.
• Ensure compliance with federal, state, and payer regulations (HIPAA, Medicare, Medicaid, etc.).
• Meet or exceed productivity and quality standards established by the RCM department.
• Participate in ongoing training to stay updated on payer policies, billing regulations, and denial trends.
• Review and research denied or underpaid claims from insurance carriers, identifying denial trends and root causes.
• Prepare and submit timely and accurate appeals with supporting medical documentation and payer guidelines.
• Communicate effectively with insurance companies to follow up on outstanding denials and appeal status.
• Collaborate with billing, coding, and client account teams to resolve discrepancies and ensure claim accuracy.
• Update claim activity notes in the system and maintain detailed documentation of actions taken.
• Identify patterns or systemic issues contributing to denials and report findings to leadership for process improvement.
• Ensure compliance with federal, state, and payer regulations (HIPAA, Medicare, Medicaid, etc.).
• Meet or exceed productivity and quality standards established by the RCM department.
• Participate in ongoing training to stay updated on payer policies, billing regulations, and denial trends.

REPORTING RELATIONSHIPS:

• This position works under general supervision, according to established procedures; decides how and when to complete tasks, and reports major activities through periodic meetings and written reports.
• This position reports directly to the RCM Manager. 

JOB REQUIRMENTS:

· High school diploma required; bachelor’s degree preferred.

· Minimum of 3 years of experience working with hospital claim denials.

· Strong analytical and problem-solving skills.

· Excellent written and verbal communication skills.

· Ability to multitask while maintaining strong attention to detail.

· Ability to work under pressure and meet tight deadlines.

· Intermediate proficiency in Microsoft Office (Excel, Word, Outlook).

· Must obtain and maintain the HBIZ Denial Recovery Specialist Certification.