Jurisdictional Analyst

Overview

This role involves serving as a Jurisdictional Analyst in the IDR process for disputed claims. Responsibilities include determining whether jurisdiction applies, evaluating whether corporate conflict of interest or prior decisions affect eligibility, reviewing medical records, and writing jurisdictional determinations to support legal and clinical resolution.

Responsibilities

• Determine whether a corporate conflict of interest prevents the organization from reviewing the dispute.
• Screen out cases covered by a prior decision involving the same parties within the designated time limit (the 90-day cooling off period).
• Determine whether other regulatory timeframes that are a prerequisite for jurisdiction have been met.
• Determine whether the case jurisdiction is state or federal.
• Write appropriate jurisdictional determinations.
  • When federal jurisdiction is appropriate, include additional information noted that would be useful to medical coders, nurses, and legal arbitrators in determining resolution of the disputed claim.
• Prioritize work and determine when issues, concerns, or discrepancies should be brought to the supervisor’s attention.
• Review medical records to assist in the final IDR determination.
• Understand, in general, how healthcare insurance functions.
• Understand state and federal medical and jurisdictional laws applicable to the IDR process.
• Exercise discretion to address potential issues before they become problems.
• Protect the confidentiality of patient information in compliance with HIPAA and HITECH.

Requirements

• Associate degree with a major in paralegal studies, or a bachelor’s degree in legal services or business administration with a major in paralegal studies and/or a Paralegal certification.
  • Relevant experience can be substituted for formal training requirements.
• Excellent attention to detail, strong proofreading and organizational skills.
• Excellent oral and written communication with internal parties.
• Ability to simultaneously manage several projects, task functions, and complex contractual requirements.
• Proficiency in Microsoft Office, including Word and Excel.
• Highly attentive to detail, with strong organizational and time management skills.
• Clear, concise, and logical writing style.
• Ability to manage competing demands with differing deadlines and work effectively with attorneys, professionals, and other staff.

Preferred Qualifications

• Knowledge of how insurance claims are processed, including an understanding of medical coding and claim rejections to help determine whether a case is part of the IDR process.
• Medical coding certification (preferred).

Compensation & Benefits

Not specified in the provided description.

Location

Not specified in the provided description.