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Operations Analyst Commercial - FCC

Company: Carle Health
Location: Pinehurst
Posted on: January 26, 2023

Job Description:

Position Summary:

The Operations Analyst position performs several key operational duties such as reviewing and researching claims, performing enrollment functions, interacting with customers via phone, email, and in person meetings and also is responsible for auditing delegated services with our partner vendors. The position also performs other support functions requiring the use of copiers, scanners, faxing, and mailing items. The position audits claim payments, tests benefit plans, reprices claims, and updates policies and procedures to ensure compliance is met.


Bachelor's Degree in Business, Management, or a related area. Significant experience may be accepted in lieu of formal education.

None specified

Five years experience in claims processing, benefit building, healthcare billing, managed care contracting, and/or patient accounting. Two years experience in customer service and/or provider service. One year experience in auditing and/or training.

Office automation/personal computer skills with excellent knowledge level in Excel, Word, and Microsoft Access. Requires strong verbal and written communication skills, conflict resolution and negotiation skills, and ability to provide strong attention to detail. Advanced knowledge of CPT coding, ICD-9 coding, and medical terminology.

Essential Functions:

  • Performs random audits of claims processed weekly to ensure quality of work and to identify root causes of errors so corrective action can be taken to fix the error.
  • Perform pre-payment review of weekly claims payment run to ensure quality and to identify errors prior to checks, EOP and EOB's being mailed so that corrections can be made without customers being affected.
  • Work all claims in daily work queues in MHS and PowerQueue systems.
  • Prepare and send all claims for re-pricing and advise claims payer of the discount amount to pay.
  • Review all refund checks to determine root cause of incorrect payment and ensure problem is corrected. Ensure deposits are made by Finance.
  • Test benefit plans and system enhancements.
  • Order and audit all overpayment reports on monthly/quarterly basis and identify root causes of incorrect payments and ensure corrective action is taken. Ensure refund letters are sent and responded to timely.
  • Assist with enrollment, provider maintenance, and COBRA administration activities. Assist with audits of these files to ensure accuracy.
  • Assist as needed in entering and auditing referrals and any other duties as assigned by FCC management.
  • Answer all customer/provider service phone calls and provide excellent level of service.
  • Meet with Providers, Members, and Groups as necessary to review claims questions/issues and ensure their resolution.
  • Attend open enrollment meetings as required to assist in educating new members and groups on their benefit plan and administrative processes.
  • Educates FCC staff on operational details and claims processing rules.

    We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. - For more information: human.resources@carle.com.

    Effective September 20, 2021, the COVID 19 vaccine is required for all new Carle Health team members. Requests for medical or religious exemption will be permitted.

Keywords: Carle Health, Fayetteville , Operations Analyst Commercial - FCC, Professions , Pinehurst, North Carolina

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