Claims Analyst

Job Description

Job Description

Claims Analyst

The Claims Analyst is responsible for the accurate and timely processing of medical, dental, and vision claims in accordance with plan provisions, policies,  and current coding standards. This role requires excellent communication skills and the ability to maintain a professional, business-like manner when interacting with co-workers, business agents,  providers, and participants—by telephone, in person, and in writing.

Classification levels within the Claims Analyst position are determined by production standards and/or expanded responsibilities within the scope of general duties.

Key Responsibilities

• Process claims for active members and retirees in accordance with plan provisions, policies,  and current codes, ensuring accurate benefit application and payment determinations.
• Review claims for coding accuracy and appropriateness, identifying potential miscoding, upcoding, duplicate billing, or non-covered procedures in alignment with plan design.
• Deliver exceptional customer service by responding to telephone, written, and in-person inquiries regarding eligibility, benefits, claim status, payment determinations, and plan procedures.
• Manage multiple deadlines while maintaining high production, coding accuracy, and compliance standards.
• Ensure compliance with applicable regulations, including HIPAA, ERISA, and internal audit standards. 
• Perform other related duties and special projects to support departmental and organizational objectives.

Minimum Qualifications

• High school diploma or equivalent required; additional education or certifications in claims processing, medical coding, dental assisting, dental hygiene, healthcare administration, or a related field helpful but not necessary.
• One or more years of experience in an automated dental claims processing environment with demonstrated success meeting production, coding accuracy, and quality standards.
• Strong customer service, communication, analytical, and presentation skills professionally.
• Proficiency in Microsoft Office applications (Word, Excel, Outlook); experience with automated claims systems and dental claims platforms required.