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Claims Operations Excellence Analyst
at Meridian
Detroit, MI

Claims Operations Excellence Analyst
at Meridian
Detroit, MI

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Description

Overview

Who we are:

 

Meridian, a WellCare Company, is part of a national network of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry.

 

We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in Michigan, Illinois, Indiana, and Ohio. As a part of the WellCare Family of companies, we deliver healthcare excellence to millions of members nationwide.

 

Our associates work hard, play hard, and give back. Meridian associates enjoy an exceptional experience and culture including special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities.

 

A Day in the Life of a Claims Operations Excellence Analyst:

 

The Claims Operations Excellence Analyst researches activities determining root cause analysis and coordinates updates with IT within the Claims Department under the direction of the department Director, Manager and Team Lead.  This position ensures that claims are processed accurately and timely in compliance with claims processing requirements as indicated in the Claims Policy and Procedure guidelines. 

Responsibilities

Essential Functions: 

  • Determine root cause analysis on claim issues that are received within the adjustment tickets
  • Work closely with the IT department to investigate and correct issues found
  • Document business and functional requirements, along with any additional artifacts to define business needs
  • Participates in logical design of system functional solutions with technical team
  • Facilitates communication between business owners and claims leadership for adjustment projects
  • Participate in QA testing, as needed
  • Create and follow up on tickets created to assist in the correction of claims issues
  • Support claims adjustment examiners with ad hoc reporting or investigate issues related to encounters or reprocessing efforts
  • Interface with internal and external personnel to resolve issues and inquiries
  • Provides post-implementation support including issue triage, analysis and resolution
  • Administer and adhere to all company and department policies and procedures
  • Proactively identify potential system issues and work with department management to develop and implement plans to address them
  • Assist Manager and Team Lead of Claims with following through on all activities related to the Claims department
  • Assist with special projects related to department process improvements, implementation of best practice while following department policies and procedures
  • Perform other duties as assigned

Qualifications

What you can bring to Meridian:

  • Pursuit of a Bachelor’s Degree or Fellow designation from the Academy for Healthcare Management (AHM) is required
  • Previous experience of at least 1 year in a claims examiner role is required
  • Knowledge of Managed Care
  • Solid understanding of the full adjudication process
  • Knowledge of all aspects of claims processin
  • Thorough knowledge of CPT and ICD-10 coding
  • Knowledge of claims policies and procedures
  • Working knowledge of PC applications
  • Working knowledge of Microsoft Office applications (Outlook, Word, Excel, Etc.)
  • Strong organizational, planning, analytical, and communication skills
  • Excellent interpersonal skills
  • Strong written and verbal communication skills
  • Excellent team-building skills
  • Effective problem-solving skills
  • Strong research and follow-through skills
  • Ability to collect, gather and analyze information
  • Ability to problem solve using critical thinking
  • Ability to prioritize work and function under time constraint
  • Ability to communicate clearly
  • Ability to maintain a professional and pleasant demeanor

What Meridian can offer you:

 

  • Our healthcare benefits include a variety of plans that are effective on the first day of employment for our new full-time team members.
  • Opportunity to work with the industry’s leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities.
  • Meridian offers 401k matching that is above the national average.
  • Full-time Meridian employees are eligible for tuition reimbursement towards Bachelor’s or Master’s degrees.
  • Meridian was named Detroit's #1 Fastest Growing Company by Crain's Magazine, so it is a great time to get involved with Meridian.

 

Equal Opportunity Employer

#MSTR

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