Claims Operations Analyst

EmpiRx Health, LLC• US,

4h•Onsite

About The Position

The Claims Operations Analyst is responsible for managing benefit and claims issues, monitoring claims trends, and processing manual claims for direct member reimbursement and subrogation requests. This role ensures operational efficiency, data integrity, and member satisfaction by identifying trends, resolving issues, and collaborating with internal and external stakeholders to enhance claims processes.

Requirements

Bachelor’s degree or equivalent experience.
1–2 years of experience in pharmacy benefit administration, operations, or a related area.
Demonstrated experience in issue management and problem resolution in a benefit context.
Familiarity with direct reimbursement processes and related systems.
Experience with eligibility and accumulator data reviews.
Strong analytical skills with ability to interpret data and identify trends.
Excellent written and verbal communication skills, with a focus on member and client satisfaction.
Proficiency in Microsoft Office Suite; prior experience with claims adjudication platforms.
Strong attention to detail, organizational skills, and ability to manage multiple priorities.

Nice To Haves

Moderate proficiency in SQL with the ability to write queries for data analysis
Demonstrated experience in process enhancements and efficiencies

Responsibilities

Investigate and resolve benefit and claim issues as identified or reported, ensuring all issues are thoroughly documented and research is clear and concise for record-keeping and preventive review.
Collaborate with internal teams to streamline and enhance issue management.
Monitor claims data to identify trends and patterns related to claim issues, including errors with eligibility and accumulators’ integration.
Conduct deep-dive analyses to identify improvement opportunities for people, processes, or systems, focusing on root cause and preventive measures.
Perform regular claims analysis to provide actionable insights that improve claim processing efficiency.
Execute the processing of direct member reimbursement requests.
Coordinate with relevant departments to address and process subrogation claims effectively.
Maintain detailed records of all manual claims processed.
Develop, maintain, and update communication materials related to benefit plan design, ensuring clarity, accuracy, and accessibility for stakeholders.
Assist in creating training resources and documentation for all operational processes managed by the team.
Partner with client services, data operations, customer service, compliance, and technology teams to enhance overall operational effectiveness.