Schedule: Monday through Friday 5:30a - 1:30p

Community Medical Services (CMS) is hiring a Claims Data Analyst responsible for reviewing and resolving denied, pended, and corrected claims. Analyzes claim resubmissions to determine areas for provider education or system re-configuration. Serves as the primary point of contact for claim issues raised by Providers and internal departments. Provides feedback on department workflows and identifies opportunities for redesign. Performs claims testing to ensure that systems are designed efficiently based on the Plan's benefit structure. Reflects a full understanding of Community Medical Services business practices, provider networks, reimbursement methodologies, and changes in reimbursement methodologies.

As you join our mission to help those suffering from substance use disorders reclaim their lives, expect to thrive in a comfortable, welcoming, and fun environment where you are valued for the work you do, championed by passionate leaders, and equipped with the tools and ongoing training you need to achieve your goals. 

Along the way, we’ll invest in your well-being through a benefits package that includes:

• Subsidized medical, dental, and vision insurance
• Health savings account
• Short and long-term disability insurance
• Life insurance
• Paid sick, vacation, and holiday time
• 401K retirement plan with match
• Tuition and CME reimbursement up to 100%
• Employee assistance program to support your mental health and wellness
• Ongoing professional development 

Responsibilities:

• Monitors and resolves high volume of claims for all lines of business, as well as claims for performance guarantee groups and high dollar claims, to minimize late payment interest penalties and ensure compliance with established guidelines.
• Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals.
• Responsible for conducting root cause analysis and working with staff in other business areas to assist with the resolution of complex Provider claim issues.
• Analyze data issues and work with development teams for problem resolutions.
• Identify problematic areas and conduct research to determine the best course of action to correct the data, identify, analyze and interpret trends and patterns in complex datasets.
• Performs other duties as assigned or required.
• Manages top tier payors claim submissions and AR Reconciliation.
• Trains and develops Billing staff when applicable.

• Bachelor’s Degree in Information Management, Healthcare Informatics, Computer Science, Business Administration, or Statistics preferred.
• Minimum of 3-5 years' experience contributing to the analysis of large medical insurance claims databases required.
• Extensive knowledge in Claims Systems Processes required.
• Proficient in MS Excel and SQL Server for testing and validating data required.
• Proficient in writing Microsoft Structured Query Language (SQL) queries required.
• Strong analytical and quantitative skills required.
• Proficient knowledge of contracts, benefits and pricing modules required.
• Advanced understanding of medical coding systems (CPT/HCPCS, ICD-9 and 10, DRG, etc. required.
• Extensive knowledge in formalizing testing strategy and detailed auditing principles and techniques required.
• Ability to manage full cycle analytical/reporting solution from requirements gathering to data modeling and report authoring required.
• Understanding of relational database concepts - Familiarity with healthcare reimbursement systems and methodologies.

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