Senior Claims Analyst

🔥 0 minutes ago

🐻 Alaska, California, +2 more states – Remote

🐻 Alaska – Remote 🏄 California – Remote 🌺 Hawaii – Remote 🗽 New York – Remote

💵 $18 - $33 / hour

⏰ Full Time

🟠 Senior

📋 Claims Specialist

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Luminare Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

⚕️ Healthcare Insurance

Healthcare Insurance

Luminare Health is a leading provider of self-funded health plan administration services with over 50 years of industry experience. The company specializes in offering flexible and innovative solutions for hospitals, health systems, and direct-to-employer initiatives, focusing on administration, cost management, and digital reporting tools. Luminare Health is dedicated to being a reliable partner in managing healthcare costs and supporting strategic growth for its clients. The company emphasizes a member-centered approach to healthcare while delivering significant savings through expert claim analysis and management of high-cost claims.

📋 Description

• Resolve client, employee/member, or provider issues regarding escalated or complex claims. • Review and release over-authority claims up to limit specified by corporate policy. • Handle claim referrals, including pre-determinations, using internal and external resources as needed. • Advise Claim Analysts and/or vendor regarding claim processing. • Handle network referrals as well as PPO repricing disputes. • Review, analyze and interpret claim forms and related documents. • Determine benefit coverage based on clinical edits, plan documents/booklets, benefit reference documents, Claim Reference Manuals and claims-related memoranda, and reports. • Appropriately investigate, pend and refer claims based on claim procedures and guidelines. • Accurately handle correspondence, claims, and referrals in the established timeframes and/or performance guarantees. • Support the Claims reinsurance team, in the research and resolution of claims as assigned. • Handle complex or technical claim adjudication using internal and external resources as needed, e.g. transplants, experimental & investigational, chemotherapy, etc. • Research and respond to vendor reconciliation requests. • Mentor and assist with onboarding new Analysts, including the oversight of work. • Support the management, monitoring, and tracking of performance in collaboration with the Supervisor. • Provide mentoring and coaching. • Assist Supervisor in documenting processes for analysts. • Other duties as needed/assigned

🎯 Requirements

• High School diploma or GED equivalent • 3 years prior medical claim processing experience • Ability to work in a fast-paced, customer centric & production driven environment • Excellent verbal and written communication skills • Ability to work effectively with employees/members, providers, clients and differing levels of co-workers including Client Managers and all levels of staff • Demonstrated critical thinking, to carry out instructions furnished in oral, written or diagram form • Flexible; open to continued process improvements • Self-directed individual who works well with minimal supervision • Good leadership, organizational and interpersonal skills • Ability to effectively handle complex situations and reach resolution • Ability to analyze and interpret documents and Summary Plan Descriptions (SPDs) • Ability to adapt to various system platforms, and to effectively use MS Excel/Word

🏖️ Benefits

• Health and wellness benefits • 401(k) savings plan • Pension plan • Paid time off • Paid parental leave • Disability insurance • Supplemental life insurance • Employee assistance program • Paid holidays • Tuition reimbursement • Annual incentive bonus plan