Senior Claims Analyst
About The Position
The Senior Claims Analyst performs highly complex and technical analysis to research, resolve, and recover health plan claims. The role coordinates departmental and project work to resolve issues and improve processes, and helps ensure that systems, processes, and reports support the Claims Administration department in meeting internal and external benchmarks. The position also serves as a subject matter expert on claims-related policies and procedures. The analyst works with Claims Administration staff and health plan business partners to resolve complex claims issues, supports inventory planning, leads operational improvement initiatives, and helps ensure compliance with applicable state and federal requirements. The role also provides coaching and training to team members while maintaining standards for quality, performance, timeliness, privacy, and ethical conduct.
Requirements
- High school graduate or GED required.
- At least five years of professional experience in claims analysis, provider medical billing, or medical coding.
- At least two years of professional experience with claims research, adjustment, and recovery.
- Any combination of education and experience that would likely provide the required knowledge, skills, and abilities is qualifying.
Nice To Haves
- Experience with Texas Medicaid is preferred.
Responsibilities
- Analyze highly complex claims and claim issues to ensure correct payment, partnering with Claims Administration staff and health plan business partners on resolution.
- Identify trends and recommend solutions for errors found through pre- and post-payment claim and recovery review.
- Assist department leadership in developing daily inventory plans based on available resources, priorities, and timeliness requirements.
- Analyze provider correspondence and review requests to determine appropriate outcomes and resolutions, escalating high-priority or high-risk issues to leadership.
- Lead departmental projects and operational improvement initiatives.
- Assist with examining, assessing, and documenting business operations and procedures to support data integrity, security, and process optimization.
- Ensure adherence to state and federal compliance requirements and reimbursement and contract policies.
- Mentor and coach team members, assist and provide feedback to less experienced staff, and lead training for new employees.
- Participate in team meetings by contributing ideas and suggestions to support departmental efficiency, quality, and teamwork.
- Maintain compliance with privacy and confidentiality standards.
- Meet or exceed established performance, quality, and timeliness standards.
- Follow ethical business practices and Health System and Health Plan policies and procedures.
- Assist with other related work responsibilities as requested.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
