Claims Analyst
About The Position
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.
Requirements
- High school diploma or GED required; five to seven years of related claims experience and/or training required.
- 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.
- 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.
- Candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.
Nice To Haves
- Associate degree preferred.
- Medical coding certification, such as CPC (Certified Professional Coder) or equivalent, preferred.
Responsibilities
- Perform daily claims audits and review professional and facility claims to identify payment errors, discrepancies, and potential high-risk claims before payment.
- Validate claims against member benefits, provider contracts, fee schedules, reimbursement methodologies, and applicable policies and regulations.
- Analyze overpayments, underpayments, duplicate payments, coding issues, and other discrepancies to identify root causes and recommend corrective action.
- Process claims adjustments, reprocessing, corrections, COB updates, refunds, and overpayment recovery activities as needed.
- Support first-level appeals and resolve complex claims-related questions from internal departments.
- Test and validate claims system, benefit configuration, and system enhancements to support accurate claim adjudication.
- Identify opportunities to improve payment accuracy, increase auto-adjudication, reduce manual processing, and strengthen operational efficiency.
- Provide guidance and training to Claims Examiners and contribute to claims procedures, SOPs, and reference materials.
- Communicate audit findings, recurring issues, and recommendations to Claims Leadership and collaborate with internal teams on resolution.
- Assist with audits, implementations, special projects, and other claims-related initiatives.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
