Claims Analyst

General Summary: The Claims Specialist is responsible for administering, processing, reviewing, and analyzing claims and provider payment activities for the LifeWays provider network. This position ensures claims are accurate, complete, appropriately documented, and processed in accordance with provider contracts, established payment parameters, LifeWays policies and procedures, and applicable local, state, and federal regulations and accreditation requirements. The position coordinates Clean Claim Review (CCR) and Medicaid Event Verification (MEV) activities; reviews electronic medical record (EMR) documentation; processes paper claims and claim reconsiderations; supports provider payment and invoicing activities; and researches and resolves claim discrepancies. The position works collaboratively with network providers and internal departments, including Finance, Utilization Management, and Contracts and Provider Network Management, to support accurate claims adjudication, appropriate provider payments, and compliance with regulatory and contractual requirements. Processes and adjudicates paper claims, including data entry, review, and application of established payment parameters, contract requirements, and applicable billing guidelines.Researches, analyzes, and corrects denied claims, when appropriate and within established authority.Manages provider payments and generates accurate and timely provider payment invoices and claim reconsideration payment invoices.Reviews claims for accuracy, completeness, appropriate coding, service units, rates, duration of services, and staff qualifications.Identifies and resolves claim discrepancies and coordinates with providers and internal departments to obtain corrections or additional information when necessary.Supports the processing and resolution of claim reconsiderations, payment disputes, and other claim-related inquiries.Ensures claims and billings comply with applicable LifeWays, provider contract, local, state, federal, and accreditation standards, policies, regulations, and procedures.Reviews electronic medical records (EMRs) to verify that required supporting documentation is present, accurate, and complete.Verifies that claims are billed against active treatment plans and that documentation supports the services, codes, units, rates, and staff qualifications reported. NOTE: The lists of essential and additional functions are not exhaustive. They may be supplemented as necessaryfrom time to time. Required Education/Certification/Licensure Bachelors degree in business, Science, Health Administration or equivalent field. Preferred Education / Certification/Licensure 1-year of experience with Community Mental Health billing, claims management or contract management; or equivalent. Certified Medical Billing Specialist