Managed Care Analyst

Day (United States of America)Managed Care AnalystThe Managed Care Analyst is responsible for managing and escalating claims, submitting Independent Dispute Resolutions (IDRs), and handling appeal escalations to Medicare; including Maximus and ALJ. This role involves monitoring and following up on all escalations to ensure timely resolution. Additionally, the analyst will manage prior authorization requirements for multiple insurance plans and ensure these are accurately loaded into the system for automation. The role also includes maintaining the standard upkeep of data to ensure accuracy and compliance, reviewing insurance plan policies and procedures for updates and changes, and resolving complex claims.

Review, evaluate and submit appropriate accounts to Independent Dispute Resolutions (IDRs), follow up and monitor their progress.

Manage and escalate claims on a project basis as necessary to ensure timely resolution.

Handle appeal review / escalations to Medicare, including monitoring and follow-up.

Review insurance plan policies and procedures for updates and changes

Communicate applicable payer policy changes for possible updates in the Epic contract management system

Maintain standard upkeep of data to ensure accuracy and compliance.

Resolve complex claims, ensuring thorough investigation and appropriate action.

Review and analyze denied claims to determine the reason for denial and identify any necessary follow-up action

Maintains current knowledge of CPT / HCPCS and ICD-10 coding in accordance with insurance payer guidelines for UB04 claim forms.

Provide accurate reporting at account level work and re-work to support managed care initiatives and track payer behaviors

Maintains knowledge of insurance payer contracts in accordance with insurance payer guidelines to ensure correct billing practices.

Contributes to effective working relationships by demonstrating a positive and helpful attitude in relationships with co-workers and customers.

Other duties as assigned.

Other Requirements & Specifications

Certification or re-certification of HFMA CRCR credential

Completion of the assigned training modules

Internal Candidates must be without infractions for twelve months

Excel Knowledge

• Bachelor's degree in healthcare administration, business, or a related field preferred.
• Minimum of 2 years of experience in managed care or a related healthcare field.
• Strong understanding of Medicare appeal processes and prior authorization requirements.
• Proficiency in EPIC and other healthcare management software and automation systems.
• Excellent organizational and communication skills.
• Ability to work independently and as part of a team.
• Detail-oriented with strong analytical skills.
• Ability to manage multiple tasks and priorities effectively.
• Proficient in data management and reporting.
• Strong problem-solving skills and ability to escalate issues appropriately.