Claims Analyst

Delta Dental of Kentucky, Inc•Louisville, KY

About The Position

The Claims Analyst researches and resolves complex claim inquiries, performs accurate claim adjustments, and partners with internal departments to ensure claims are processed in accordance with applicable benefits, policies, procedures, and regulatory requirements. The position provides production support for complex claims, identifies root causes of processing issues, documents findings, and recommends practical improvements that promote payment accuracy, timely resolution, and a consistent member and provider experience.

Requirements

Bachelor’s degree in business, healthcare administration, or a related field; an equivalent combination of education, training, and relevant work experience will be accepted.
Three to five years of experience in dental or health insurance, claims processing, benefits administration, or a related operational environment is preferred.
Strong analytical, research, and problem-solving skills.
Ability to interpret benefit plans, policies, procedures, and claim documentation.
Attention to detail and ability to use independent judgment.
Effective written and verbal communication skills.
Ability to manage competing priorities while meeting quality and turnaround-time expectations.
Proficiency with claim processing systems and Microsoft Office applications, particularly Outlook, Word, Excel, and Teams.
Ability to learn new systems, protect confidential information, and work effectively in a production-oriented environment.
Infrequent overnight travel may be required.

Nice To Haves

Experience with claim adjustments, issue resolution, root-cause analysis, or quality review is preferred.

Responsibilities

Respond to claim follow-ups and inquiries from Customer Service and other internal departments, providing clear, accurate, and timely resolution.
Research complex claim issues by reviewing benefit plans, claim history, provider information, supporting documentation, and applicable processing guidelines.
Perform claim adjustments and corrections to support accurate payment, member liability, and explanation of benefits information.
Partner with internal departments to troubleshoot claim issues, determine root causes, and coordinate appropriate resolutions.
Track recurring claim issues, identify trends, and communicate findings and recommendations to Claims leadership and business partners.
Apply benefit, policy, procedure, and regulatory requirements consistently when analyzing and adjusting claims.
Document research, decisions, adjustments, and communications thoroughly in the appropriate systems.
Escalate high-risk or unusual claim situations in accordance with established procedures and authority levels.
Support claim system testing, process changes, and implementation activities by validating claim outcomes and reporting identified issues.
Maintain current knowledge of claim processing procedures, benefit configurations, products, and system updates.
Meet established quality, productivity, accuracy, and turnaround-time expectations.
Proactively identify opportunities to improve claim accuracy, operational efficiency, and the internal customer experience.
Perform other related duties as assigned.