Claims Analyst II

This position is responsible for day-to-day examination, validation and processing of “Hospitals”claims received by the Company, according to its policies, processes instructions and systems. Responsible to the research and documentation of special conditions or additional requirements data for claims adjudication. All staff will adhere to all operational policies and processes related to the SNP product. Staff will attend all trainings per guidelines of the MOC related to the functions of enrollment, customer service, provider relations/contracting, credentialing, as needed. Staff will notify supervisor of any processes not in compliance with the Plans’ SNP policies and MOC requirements.


1. Examine and validate claims in a timely and accurate manner.
2. Process claims until validation, to include adjustments, C.O.B. and M.S.P. claims.
3. Prepare claims until its validation process for providers and members, on denial or adjusted claims.
4. Research and document results of claims; either for special consideration, conditions or additional data.
5. Resolve complex claim issues.
6. Interface with personnel of the different areas of the company to ensure the resolution of problems around the claims, such as, correct validation, and timely payment services.
7. Participate with the Claims Supervisors in the preparation of recommendations or guidelines oriented to approach the resolution of claims patters. Also, participates in the research, validations and resolution of claims new patter.
8. Assign Non Plan Providers to existent claims.
9. Report any problem that may affect the claims process.
10. Price DRG and APC Payments in hospital claims.
11. Analyze and process paper and electronic claims according with the established policies and procedures.
12. Alert a Claims Supervisor for all situations identified in Qnxt System that affect the processing cycle of claims.
13. Special projects could be assigned.


Associate's degree or equivalent from two-year college or technical school. More than 1 year experience processing “HF1500” claims and 1 year of experience processing “UB04” claims; or equivalent combination of education and experience.


Ability to read, analyzes, and interprets general business periodicals, cms regulations, technical procedures, or sate and governmental regulations. Ability to write reports and business correspondence. Ability to effectively present information and respond to questions from claims supervisor, groups of managers, clients, customers, and the general public.


Ability to add, subtracts, multiply, and divides in all units of measure, using whole numbers, common fractions, and decimals.


Ability analize and solve practical or technical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form


1. Effective interpersonal communication and Customer Service Skills: practicing, valuing and supporting service to both internal and external customers.
2. Time Management Skills: establishing priorities and accomplishing daily tasks in a timely manner
3. Self-directed with good organizational skills.
4. Ability to work in a fast paced/dynamic team environment.
5. Must be available to work extended hours if there is a business need.
6. Sense of urgency and accountability
7. Billingual (English/Spanish)
8. Knowledge in Qnxt System
9. Knowledge in Microsoft applications: Excel, Word, Power Point, Access


While working the employee is sitting. Performed tasks require independent knowledge and judgment in addition to provided instructions and procedures. Must be able to function with frequent interruptions, accept change and able to prioritize activities when faced with competing demands.


Normal busy office environment. Moderate noise (examples:business office with computers and printers, light traffic)

This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.