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JOB SUMMARY: The Claims Adjustment Analyst II supports the review and resolution of complex level payment disputes including corrected claims; retro authorizations, incorrect denial requests, reconsiderations and provider payment appeals in a timely manner. This position is responsible for processing medical and dental claims, using industry standard practices for medical claims processing. The Claims Adjustment Analyst II applies relevant rules and regulations specific to coding, providers, plan benefits, contracts, state and federal guidelines as well as Community Health Choice's policies and procedures.

MINIMUM QUALIFICATIONS:

1. Education/Specialized Training/Licensure: High school Graduate
2. Work Experience (Years and Area): 4 years of claims adjustment experience in multiple lines of business (both Marketplace and HHSC.)
3. Software Operated: Microsoft Office (Word, Excel, Outlook)

Other Requirements:

• Sound analytical problem-solving and documentation skills.
• Ability to speak, listen and write effectively.
• Quick learner with the ability to adjudicate professional and facility claims, applying appropriate reimbursement methodologies.
• Ability to problem solve and work independently.
• Team player with the ability to establish and maintain effective work relationships

SPECIAL REQUIREMENTS:

1. Communication Skills:
Writing /Composing: Correspondence / Reports

2. Other Skills: Analytical, Mathematics, Medical Terminology, Research, MS Word

3. Advanced Education: N/A

4. Work Schedule: Flexible, Overtime

RESPONSIBLE TO: Supervisor/Manager