• Claims/Data Analyst- MLTC

    Job Locations US-NY-Staten Island
    ID 2018-1139
    Non-Clinical- MLTC
    Regular Full-Time
  • Overview

    Representative will be responsible for assisting in service claim review and other data analysis, assisting with provider claim inquiries/appeals, and supporting the department as needed.


    • Utilizes excellent customer service skills to provide administrative support, information, education, and direction to all MLTC members/providers
    • Able to assist in the resolution of provider claim issues
    • Responsible for reviewing claim denial reports to ensure claims processing accuracy and sending instructions for claims to be processed/reprocessed according to clinical or       administrative determinations of service coverage
    • Assisting with investigations of provider claim appeals, review of audit claims summary data and reporting of findings to supervisor/manager
    • Responsible for reviewing and resolving pended claims sent for Extended MLTC review and determination
    • Identifying claims resulting in non-reportable encounters and facilitating resolutions
    • Assisting with provider outreach regarding claims resubmission and general claims submission/billing education
    • Coordination with supervisors, managers, and all appropriate staff necessary to determine service coverage and appropriate provider payments or denials
    • Responsible for compiling claim data for both internal inquiries & for State reporting purposes as needed
    • Performing retrospective review of service authorizations and service utilization (based on claims data) to identify potential capitation paybacks
    • Responsible for running system reports as required to identify necessary data for interdepartmental and company use
    • Able to direct calls to appropriate staff members and assist with translation needs as able/required
    • Able to address queries from enrollees or providers regarding the MLTC program and any of its policies and procedures
    • Able to direct calls to appropriate staff members and ensure that all measures are taken to assist members/providers
    • Coordinates appropriate communication and documentation between members, agency, medical professionals, and referral sources
    • Performs other duties as assigned
    • Assisting in training new incoming staff members on departmental responsibilities as needed
    • Adheres to all applicable regulations, policies, and procedures of the MLTC plan


    • High School Diploma or GED required
    • Previous experience with health plan operations preferred
    • Experience in dealing with the Managed Care industry preferred
    • Experience with financial/data analysis preferred
    • Strong research and analytical skills preferred


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