Claims Analyst

Claims Analyst

The Claims Analyst researches and resolves complex claim inquiries, performs accurate claim adjustments, and partners with internal departments to ensure claims are processed correctly and in accordance with applicable benefits, policies, procedures, and regulatory requirements. This position provides production support for complex claims, identifies root causes of processing issues, documents findings, and recommends practical improvements that promote payment accuracy, timely resolution, and a consistent member and provider experience.

Primary Job Responsibilities

• Respond to claim follow-ups and inquiries from Customer Service and other internal departments, providing clear, accurate, and timely resolution.
• Research complex claim issues by reviewing benefit plans, claim history, provider information, supporting documentation, and applicable processing guidelines.
• Perform claim adjustments and corrections to support accurate payment, member liability, and explanation of benefits information.
• Partner with internal departments to troubleshoot claim issues, determine root causes, and coordinate appropriate resolutions.
• Track recurring claim issues, identify trends, and communicate findings and recommendations to Claims leadership and business partners.
• Apply benefit, policy, procedure, and regulatory requirements consistently when analyzing and adjusting claims.
• Document research, decisions, adjustments, and communications thoroughly in the appropriate systems.
• Escalate high-risk or unusual claim situations in accordance with established procedures and authority levels.
• Support claim system testing, process changes, and implementation activities by validating claim outcomes and reporting identified issues.
• Maintain current knowledge of claim processing procedures, benefit configurations, products, and system updates.
• Meet established quality, productivity, accuracy, and turnaround-time expectations.
• Proactively identify opportunities to improve claim accuracy, operational efficiency, and the internal customer experience.
• Perform other related duties as assigned.

Minimum Qualifications

Position requires a bachelor's degree in business, healthcare administration, or a related field, with three to five years of experience in dental, health insurance, claims processing, benefits administration, or a related operational environment preferred. Will accept an equivalent combination of education, training, and relevant work experience. Position requires strong analytical, research, and problem-solving skills; the ability to interpret benefit plans, policies, procedures, and claim documentation; attention to detail and the ability to use independent judgment; effective written and verbal communication; and the ability to manage competing priorities while meeting quality and turnaround-time expectations. Experience with claim adjustments, issue resolution, root-cause analysis, or quality review is preferred. Position also requires proficiency with claim processing systems and Microsoft Office applications, particularly Outlook, Word, Excel, and Teams. The ability to learn new systems, protect confidential information, and work effectively in a production-oriented environment is essential. Infrequent overnight travel may be required.

Delta Dental of Kentucky, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity, national origin, or veteran status.