Operations Analyst Commercial - FCC
Company: Carle Health
Posted on: January 26, 2023
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
CERTIFICATION & LICENSURE REQUIREMENTS
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
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
- 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
- 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
- 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
- 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
- Educates FCC staff on operational details and claims processing
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:
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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