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Position Summary / Scope of Responsibility:
MedVanta is the nation's largest physician-owned musculoskeletal (MSK) platform, dedicated to helping individuals prevent injuries, improve movement, recover from musculoskeletal conditions, and access high-quality MSK care. Through a combination of innovative technology, clinical expertise, data-driven insights, and care navigation services, MedVanta delivers solutions that support prevention, performance, treatment, recovery, and long-term musculoskeletal health.
MedVanta has an employee-centered culture that supports and promotes diversity and inclusion. Our encouraging and empowering management style makes MedVanta a great place to further grow your knowledge while building a team driven path to success.
The Healthcare Account Analyst is the liaison between MedVanta DTE Clients and our MSK services. This job reviews, evaluates, and processes various Stop Loss (Excess Risk and Reinsurance) claims in accordance with established turnaround and quality standards. Responsible for building positive client relationships, providing education, and analyzing client claim losses as well as current issues regarding client claim activities; disseminates necessary information and reporting to management and clients. Follows up on pended claims in accordance with department standards.
Primary Responsibilities:
The incumbent may be asked to perform job-related tasks other than those specifically stated in this description. The duties and responsibilities of the position are to be carried out in a manner that is consistent with the Mission, Core Values and Operating Principles of MedVanta.
• Processes daily incoming claims and aggregated Stop Loss claims including initial entry claims or subsequent claims as needed; provides counseling to clients and assists with client service programs.
• Evaluates various claims submitted by Third Party Administrators (TPAs) and Pharmacy Benefit Managers (PBMs) on behalf of self-funded clients for compliance with the following: underlying policy provisions, federal and state regulatory guidelines, and industry standards.
• Monitors, reviews and analyzes various complex potential claims with emphasis on controlling losses through effective managed care. This includes following a departmental claim checklist to ensure eligibility is met, the payment reimbursement request is accurate by auditing the claim for duplicate line-item charges and determining if all information is available to finalize the payment request. Refers the claim to the cost containment and RxOps departments for review of high dollar charges if applicable.
• Determines whether to pend or adjudicate claims following organizational policies and procedures; finalizes and adjudicates claims up to pre-determined dollar threshold. Completes pended claim letters for incomplete, invalid, or missing claim information to TPAs, brokers, or customers utilizing the appropriate application and/or template.
• Identifies potential discrepancies in claim submissions and involves the Special Investigation Unit as necessary. Identifies issues which can be used to educate/train internal staff, streamline, and improve processes and update documentation.
• Assists leadership with performing client performance evaluations to assess the accuracy of client reports submitted to the organization, efficiency of claim operations, and adequacy of systems and procedures.
• Approves claim payments on behalf of multiple clients and provides client counseling and support services. Assists in the client service programs including revising and establishing procedures, protocols and ensuring client satisfaction with the organization.
• Maintains accurate claim records.
• Maintains the system accuracy and resolves any technical issues identified.
• Creates, runs and tracks all benefit reports required by the client.
• Creates and deploys monthly aggregator reports.
• Other duties as assigned or requested.
Required Education and Experience:
EDUCATION
Required
• High School Diploma/GED
Preferred
• Bachelor's degree in Business Administration or equivalent
EXPERIENCE
Required
• 5 years of relevant, progressive experience in health insurance claims
• 3 years of prior experience processing 1st dollar health insurance claims
• 3 years of experience with medical terminology
Preferred:
• 3 years of experience in a Stop Loss Claims Analyst role.
• 2 years of experience using WEX
Competencies / Required Skills and Abilities:
• Proficiency in MS Excel
• Proficiency in creating and managing Power BI or similar benefits reporting.
• Ability to communicate concise accurate information effectively.
• Strong organizational skills
• Ability to manage time effectively.
• Ability to work independently.
• Problem Solving and analytical skills.
• Strong interpersonal skills - ability to develop relationships and collaborate and influence in a centralized organization.
• Demonstrated ability to organize, prioritize, and manage multiple tasks in a dynamic environment with a proven track record of results.
• Strong interpersonal, oral, and written communication skills with excellent self-discipline and patience.
• Exudes professionalism in presentation.
• Must be able to read, write, speak, understand, and communicate in the English language.
Physical Demands:
• Must be able to sit for long periods of time and lift up to 25 pounds
• Must be able to use appropriate body mechanics techniques when performing desk duties.
• Requires frequent bending, reaching, repetitive hand movements, standing, walking, squatting, and sitting.
• Adequate hearing to perform duties in person and over telephone.
• Must be able to communicate clearly to individuals in person and over the telephone.
• Visual acuity adequate to perform job duties, including reading materials from printed sources and computer screens.
Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.