SR. CLAIMS SPECIALIST with rapidly growing healthcare company - SSF or Cupertino!

PRINICIPAL DUTIES: 

? Analyze and evaluate membership and medical/pharmacy claims data from  Insurance Companies, HMO?s, and Third Party Payors to provide data clean up identification

? Review  contract/requirements, customer data layout,  and data mapping requirements

? Provide analytical insight into claims data submitted to determine appropriate mapping into existing and planned database structures.

? Provide an experienced understanding of what medical claim data elements mean and how they will be utilized in medical and statistical analysis to validate appropriateness.

? Perform QA functions via SQL to ensure accuracy of medical, pharmacy and membership data submitted to determine data integrity, anomalies, statistics and trending

? Expert-level knowledge of claims and reporting business processes, data exchange architecture, and client data transfer methodology.

? Support the creation of extraction, transformation, and loading processes of data into a Claims Data Warehouse and other subsets of data required for specific reporting uses or projects

? Assist in the design and implementation of business processes, system interfaces, system testing, issue management, scheduling, documentation, training, system administration, status meetings and all other project-related proceedings.

? Provide industry knowledge to technology and business colleagues

 

RequirementsMinimum of 5 years of claims processing experience or claims data analysisKnowledgeable in the HIPAA compliant ANSI standard layouts (e.g. 8371, 837P, 837D and 834) Knowledge of claims processing system functionality and output Care Management/Disease Management familiarity a plusSQL server to develop ad-hoc reports/queries to conduct day analysis and validationExperience in Testing (System and Integration testing) with any of the
industry standard testing tools

 

NOTE:  Position can either be in SSF or Cupertino!

 

About LifeMasters

LifeMasters has been a leader in healthcare, specializing in disease management since 1994. With an extensive client list of healthcare payors including Aetna, Medicare, and Medicaid, LifeMasters helps chronically ill individuals achieve and maintain optimal health which can lead to a reduction in hospitalizations, emergency room visits and overall medical costs. By combining communications and technology with ongoing healthcare coaching and nursing support, we provide individuals and their physicians with the necessary tools, education and training to better manage their health.

 

For immediate consideration, please send a WORD copy of your resume to JobsIT@LifeMasters.com .