Claims Analyst

Job Description

Job Description

Job Title: Claims Analyst

Reports To: Supervisor of Claims

This is a non-exempt position responsible for reviewing, analyzing, and adjudicating non-routine health claims that could not be system adjudicated for payment. Analyst must research and interpret summary plan description language and make accurate determination for adjudication or denial of claim. Analyst must also assist in determining cause for manual intervention, then assist in writing logic and workflow automation for future claims.

Brief Description of Duties:

• Review incoming medical, pharmacy vision and dental claims 
• Determine and apply appropriate health plan benefits and update claims for payment
• Ensure timely and accurate claims adjudication
• Follow company guidelines and policies for adjudicating claims and responding to members
• Act as a resource for questions, opportunities, and research issues for all internal and external customers
• Responsible for meeting performance measurement standards for productivity and accuracy
• Identify and resolve operational problems using defend processes, judgment, and expertise
• Provide feedback to team members regarding process improvement opportunities
• Asset with training and mentoring of new team members
• Resolve identified claims issues based on CCI edit repot to comply with CMS guidelines.
• Represent the department when needed for internal and external company meetings
• Complete special projects (including research) as assigned by Claims Supervisor or Director of Claims
• High level understanding of state and federal laws specific to health plan administration (HIPPA, ERISA, MHPAEA, ACA Mandates etc.)
• Develop and maintain statistical data as required
• Assist in departmental reporting

Minimum Skills Requirement:

• Post-secondary education or two years experience in a claims processing environment
• Experience in Medicare Advantage strongly preferred
• Excellent communications (oral and written) skills
• Intermediate skill levels in Microsoft Word, Excel, and Outlook preferred
• Ability to work at a self-directed pace in a changing, multi-task environment
• Detail oriented
• Professional appearance and presence
• Commitment to support and maintain confidentiality in conformance to HIPAA guidelines

Other:

• Confirmation of excellent attendance record in current or most recent job
• General knowledge and understanding of claims processing functions

 

We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses and identifying potential inconsistencies or verification signals in application materials based on available information. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.