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HEALTH CARE ANALYST
The Health Care Analyst is responsible for examining provider and recipient insurance claims and records, identifying and resolving payment problems under the Medicaid system, and coordinating staff and program activities. This position is governed by state and federal laws and agency/institution policy.
Class Code:
L070C
Job Grade:
GS05
Special Job Requirements:
None
Typical Functions:
Examines claim forms, computer files, and other records to ensure compliance with claim requirements, determine eligibility status, and/or identify and resolve problems with claim payments. Reports irregularities of insurance claim payments to supervisor and prepares correspondence regarding findings to notify involved parties. Interviews involved parties to obtain additional or clarifying information and documents interview and paperwork or medical records. Approves or denies claim based on information, initiates changes to computer files, maintains log of corrections, and notifies involved parties of corrections or status of claim. Provides technical assistance to requesting parties by researching claim, disseminating eligibility and policy and procedure information, answering questions regarding claim status, and updating provider pricing schedules. Conducts regular or special surveys and studies, compiles data, analyzes information, and prepares related reports. Performs other duties as assigned
Knowledge, Abilities, and Skills:
Knowledge of state and federal laws and regulations and agency policy governing health care. Knowledge of medical insurance claims procedures. Knowledge of medical terminology and records. Ability to analyze medical claims and reports in accordance with established criteria. Ability to interpret and apply state and federal laws and agency policy governing health care. Ability to prepare and present verbal and written information, correspondence, and reports.
Minimum Qualifications:
The formal education equivalent of a bachelor’s degree in general business, business education, office management systems, management, or a related field; plus one year of experience in documents examination, claims examination, or a related field. OR The formal education equivalent of an associate degree in office occupations, business education, business management, or a related field; plus three years of experience in documents or claims examination or a related field. Additional requirements determined by the agency for recruiting purposes require review and approval by the Office of Personnel Management. OTHER JOB RELATED EDUCATION AND/OR EXPERIENCE MAY BE SUBSTITUTED FOR ALL OR PART OF THESE BASIC REQUIREMENTS, EXCEPT FOR CERTIFICATION OR LICENSURE REQUIREMENTS, UPON APPROVAL OF THE QUALIFICATIONS REVIEW COMMITTEE.
Required Certificates:
None
Exempt:
N
