Senior Claims & Participant Services Specialist

Senior Participant Services Analyst (Healthcare Claims & Benefits)

About the Role

We are seeking an experienced Senior Participant Services Analyst to join our Claims team. This highly visible role serves as a key point of contact for health plan participants, providers, hospitals, and physicians while also supporting process improvement initiatives across claims operations.

The ideal candidate has extensive healthcare claims experience, thrives in a customer-focused environment, and possesses strong analytical and problem-solving skills. This position offers the opportunity to make a meaningful impact by improving participant experiences, resolving complex claims issues, and contributing to operational excellence.

Key Responsibilities
Participant & Provider Support
Deliver exceptional service to participants, providers, physicians, hospitals, and other stakeholders.
Respond to inquiries regarding benefits, eligibility, claims, billing, payments, authorizations, and Explanation of Benefits (EOBs).
Research and resolve complex participant and provider issues.
Communicate clearly and professionally to ensure understanding and timely resolution.
Document customer interactions accurately and completely.
Claims Processing & Research
Review, research, and process healthcare claims accurately and efficiently.
Verify claim information, pricing, authorization requirements, eligibility, and applicable benefits.
Apply benefit plan provisions, claims policies, regulatory requirements, and established procedures.
Investigate and resolve discrepancies related to claims payments and eligibility.
Analysis & Process Improvement
Analyze existing workflows, policies, and operational procedures.
Identify opportunities to improve efficiency, accuracy, and participant satisfaction.
Develop and maintain process documentation, flowcharts, policies, and standard operating procedures.
Conduct research and analysis related to healthcare benefit trends and operational performance.
Identify control weaknesses and recommend solutions.
Support implementation of business process improvements and system enhancements.

Team Support
Coach and train less experienced team members.
Contribute to a collaborative and positive team environment.
Share knowledge and best practices across the department.

Qualifications
Required
Bachelor's degree in Healthcare Administration, Business, Mathematics, Engineering, or a related field; equivalent experience may be considered.
Minimum 4 years of healthcare claims processing experience.
Minimum 4 years of experience in a high-volume call center or participant services environment.
Strong knowledge of healthcare claims adjudication, eligibility verification, and benefits administration.
Knowledge of medical terminology.
Excellent customer service, communication, and interpersonal skills.
Strong analytical and problem-solving abilities.
Proficiency with Microsoft Office, including Excel, Word, and Outlook.
Ability to manage multiple priorities in a fast-paced environment.

Preferred
Experience working with health plans, third-party administrators (TPAs), unions, trust funds, or benefits administration organizations.
Experience with Medicare or regulatory compliance requirements.
Process improvement, workflow analysis, or business analysis experience.
Experience creating policies, procedures, and process documentation.
What Makes You Successful
You enjoy solving complex problems and investigating claim-related issues.
You can balance customer service excellence with operational accuracy.
You are detail-oriented, organized, and accountable.
You thrive in environments that require sound judgment and independent decision-making.
You embrace change and continuously look for ways to improve processes and outcomes.

Schedule

This is a full-time position working 40 hours per week, Monday through Friday. Fully remote 1-3x in office required. Flexibility is required to work core business hours and occasional overtime as business needs dictate.

Why Join Us?
Meaningful work supporting healthcare participants and their families.
Collaborative and mission-driven culture.
Opportunity to influence operational improvements and business processes.
Professional growth and development opportunities.
Competitive compensation and benefits package.

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, Los Angeles County Fair Chance Ordinance, and San Francisco Fair Chance Ordinance.