Claims Analyst Jobs

About The Position

Requirements

• At least 2 years of experience in previous roles in a managed care organization, health insurance, or a directly adjacent field, or an equivalent combination of relevant education and experience.
• Knowledge of policy and government legislative review.
• Strong analytical and problem-solving skills.
• Robust knowledge of the Office Product Suite, including Word, Excel, Outlook, and Teams.
• Previous success in a dynamic and autonomous work environment.
• Working knowledge of healthcare claims, medical billing, reimbursement methodologies, and coding systems, including CPT, HCPCS, ICD-10, revenue codes, modifiers, and claim types.
• Ability to research reimbursement and coding policies and translate policy requirements into actionable claims logic and business requirements.
• Ability to analyze claims data to identify billing patterns, potential overpayments, and Payment Integrity recovery opportunities.

Nice To Haves

• Experience working with healthcare claims, medical billing or coding, reimbursement, Payment Integrity, claims auditing, or an equivalent claims-focused function.
• Payment Integrity or post-pay claims recovery experience.
• Experience developing or supporting claims edits, payment policies, recovery concepts, or reimbursement rules.
• Experience with CMS, NCCI, Medicare, Medicaid, and/or state-specific reimbursement guidance.
• Medical coding certification such as CPC, CCS, COC, or equivalent.

Responsibilities

• Research and develop post-pay Payment Integrity recovery concepts and claims edits by evaluating healthcare claims, reimbursement patterns, medical billing and coding requirements, and applicable regulatory and payer guidance.
• Research and interpret CMS, NCCI, state Medicaid, Medicare, and other applicable reimbursement and coding requirements to support defensible claims-recovery logic.
• Translate Payment Integrity opportunities into detailed business requirements, including claim logic, coding criteria, inclusions, exclusions, and supporting documentation for analytic and technical development teams.
• Analyze claims data to identify billing patterns, potential overpayments, and opportunities for Payment Integrity recovery concepts.

Benefits

• Competitive benefits and compensation package.