SAU Analyst

$56,160 - $60,320/Yr

Curative HR LLC - Austin, TX

Full-time - Mid Level

Austin, TX

About the position

Curative is seeking a dedicated Analyst to review claims for completeness and ensure compliance with plan guidelines. This role involves processing claims, conducting audits, and managing detailed projects across various lines of business while maintaining confidentiality and promoting the organization's mission.

Responsibilities

• Review claims, appeals, and reconsiderations for compliance with plan guidelines and approve or deny payment using established guidelines, policy, and procedures.
• Document all claims adjudication decisions clearly and concisely in Claim Notes.
• Consult appropriate reference materials to verify proper coding.
• Identify potential problems and claims training issues during the review of claims referrals and appeals; refer for resolution to manager and track claim processing errors.
• Interpret and apply plan guidelines while processing to ensure correct plan setup.
• Coordinate adjudication of claims against the eligibility of individual enrollees as well as authorizations and benefit verification.
• Proactively identify processes and system problems that can be improved to reduce rework and ensure accurate payment upon original processing.
• Maintain timely responses to appeals and reconsideration requests.
• Handle special projects as dictated by the client's request.
• Review for claim payment accuracy and member out-of-pocket calculation accuracy, if applicable.
• Adhere to rules and regulations of Curative as described in the employee handbook and in the unit/department/clinic procedures.
• Create databases, spreadsheets, or tables as required for special projects and ad hoc reporting assignments.
• Provide review and mentoring for other SAU Analysts and Claims department.
• Perform other duties, functions, and projects as assigned by team management.

Requirements

• At least 3 years of experience in claims benefit review/adjudication and adjustments, including PPO and/or Medicaid.
• Experience with various claim payment systems in processing hospital, mental health, dental, and routine medical claims within given deadlines.
• Experience working on/with the HealthEdge claims system is extremely beneficial.
• At least 3 years of auditing experience.
• Knowledge of medical terminology, ICD-10, CPT, and HCPCS coding, TDI and CMS regulations, and multi-state regulation/audit experience required.
• Working knowledge of Google, MS Access, and Excel preferred.
• Excellent computer and keyboarding skills, including familiarity with Windows.
• Excellent interpersonal and problem-solving skills.
• Excellent verbal and written communication skills to communicate clearly and effectively with all levels of staff, members, and providers.
• Ability to be detail-oriented, focused, and sit for extended periods at a computer workstation.
• Ability to work in a team environment and manage competing priorities.
• Ability to calculate allowable amounts such as discounts, interest, and percentages.