Claims Analyst

Job Description

Job Description

POSITION SUMMARY

The Claims Analyst supports accurate and timely claims payment through pre-payment audits, claims analysis, and payment integrity activities. This role reviews professional and facility claims, identifies payment discrepancies, evaluates claims against benefits, contracts, reimbursement methodologies, and applicable policies, and works with internal teams to resolve issues and improve claims processing. The position also supports claims adjustments, system testing, process improvements, and training.

Make an impact beyond processing claims. In this role, you'll use your claims expertise and analytical skills to protect payment accuracy, identify opportunities for improvement, and help strengthen the processes that support our members and providers.

QUALIFICATIONS

• High school diploma or GED required; five to seven years of related claims experience and/or training required. Associate degree preferred .
• Medical coding certification, such as CPC (Certified Professional Coder) or equivalent, preferred .
• Familiarity with ICD-10-CM, HCPCS Level II and III, CPT, revenue codes, and Diagnosis-Related Group (DRG) coding on UB-04 and CMS-1500 claim types.
• Strong knowledge of medical claims processing/adjudication, fee schedules, provider contracts, coverage, reimbursement policies, and claims processing standards.
• Ability to analyze claims issues, identify root causes, communicate findings, and train others effectively.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Perform daily claims audits and review professional and facility claims to identify payment errors, discrepancies, and potential high-risk claims before payment.
2. Validate claims against member benefits, provider contracts, fee schedules, reimbursement methodologies, and applicable policies and regulations.
3. Analyze overpayments, underpayments, duplicate payments, coding issues, and other discrepancies to identify root causes and recommend corrective action.
4. Process claims adjustments, reprocessing, corrections, COB updates, refunds, and overpayment recovery activities as needed.
5. Support first-level appeals and resolve complex claims-related questions from internal departments.
6. Test and validate claims system, benefit configuration, and system enhancements to support accurate claim adjudication.
7. Identify opportunities to improve payment accuracy, increase auto-adjudication, reduce manual processing, and strengthen operational efficiency.
8. Provide guidance and training to Claims Examiners and contribute to claims procedures, SOPs, and reference materials.
9. Communicate audit findings, recurring issues, and recommendations to Claims Leadership and collaborate with internal teams on resolution.
10. Assist with audits, implementations, special projects, and other claims-related initiatives.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

SKILLS AND ABILITIES

• Strong analytical and problem-solving skills.
• Ability to work independently with minimal supervision while managing multiple priorities.
• Strong written and verbal communication skills.
• Ability to build effective working relationships with internal and external customers.
• Ability to maintain professionalism and composure in a fast-paced environment.

Work Schedule:

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. A reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee may occasionally be required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. A reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.

Background Screening Notice:
In compliance with Florida law, candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

The Clearinghouse is a statewide system managed by the Agency for Health Care Administration (AHCA) and is designed to help protect children, seniors, and other vulnerable populations while streamlining the screening process for employers and applicants.

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