Senior claims specialist vs medical claims analyst

Differences between senior claims specialist and medical claims analyst duties and responsibilities

Senior claims specialist example responsibilities.

• Manage assigned third party administration (TPA) multi-jurisdictional workers' compensation; subrogation recovery claims; assign defense attorney.
• Work toward settlement with claimants and attorneys, or determine company litigation strategy, participating in mediation and arbitration when necessary.
• Maintain EDI processing table logic.
• Work with testing HIPAA transactions, reporting and processing data reporting to the state.
• Review data entry of claims receive through the EDI system for accuracy prior to processing.
• Operate within all company regulations regarding HIPAA, fraud, confidentiality, and private health information guidelines.
Show more

Medical claims analyst example responsibilities.

• Manage cases by aggressively directing the litigation process.
• Analyze incoming medical claims using ICD-9, CPT, HCPCS coding, and Medicare fee schedules.
• Determine if claims are in compliance under patient benefit plans for payments using DRG regulations :
• Review medical records to determine if the ICD-9, CPT codes and modifiers are processed correctly.
• Adhere to the HIPAA privacy, security regulations, and maintain confidentiality of patient a business records.
• Research medical claims issues in response to informational inquiries by accessing and interpreting EOB's and claims history.
Show more