Senior Claims Analyst

Senior Claims Analyst (199) - Remote

As a Senior Claims Analyst, you will leverage healthcare claims expertise and data analysis to identify overpayment opportunities, develop new audit concepts, and deliver value across multiple client programs. This role partners closely with cross-functional teams to research complex claims scenarios, improve processes, and support innovative solutions that drive accuracy and financial results.

JOB SUMMARY

This role recognizes and reports new concepts for development with minimum assistance. The incumbent might be tasked to multiple clients and/or programs. They also understand the data mining process and will occasionally be tasked with training and assistance on process improvements.

JOB DUTIES

1. Researches new concepts for development to determine applicability to client requirements.
2. Effectively utilize department tools to research concepts as appropriate, including but not limited to:
   • Client Claims Processing Policies/Systems
   • CMS/OIG/RAC Public Information
   • Provider/Member Contracts
   • State Medicaid Plans Public Information
   • Review of Adjustment Claims
3. Document new concepts in an appropriate format outlined by management.
4. Partner with Microsoft SQL developers to develop efficient output of concepts following the concept development process as defined by management.
5. Communicate to management any issues that impact work performance and work with management to resolve them.
6. Provide appropriate feedback to management on areas of improvement.
7. Aid in the training and mentorship of new team members as appropriate.
8. Document how to validate overpayments at a conceptual level.
9. Aid in the documentation of concept approval forms for clients as necessary.
10. Collaborate, coordinate, and communicate across disciplines and departments.
11. Ensure compliance with HIPAA regulations and requirements.
12. Demonstrate company core competencies and values.
13. Due to exposure of PHI sensitive data, this role is considered a High Risk Role.
14. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.

REQUIREMENTS

• Minimum high school diploma and two (2) years' experience analyzing medical claims paid/processed data. Bachelor's degree in a relevant field of study is strongly preferred.
• Experience on multiple claims processing platforms.
• Experience working across multiple clients with varying claims processing policies.
• Experience with various types of medical healthcare claims, including:
  • Inpatient
  • Outpatient
  • Professional
• Experience with various types of medical healthcare payment methods, including:
  • DRG
  • Per Diem
  • Outpatient Surgery Groupers
  • RUG
  • OASIS
  • Fee Schedule
• Required licensures, professional certifications, and/or board certifications as applicable.
• Ability to recognize new concepts that lead to overpayments.
• Ability to work efficiently across multiple clients.
• Experience utilizing tools to identify new concepts on data (ReThink Analyzer).
• Strong attention to detail and proven problem-solving abilities.
• Excellent written communication skills.
• Effective time management skills.
• Flexibility during times of change.
• Highly self-motivated.
• Ability to quickly apply new technologies/techniques and adapt to shifting priorities and timelines.
• Ability to work in a standard office environment, including prolonged sitting, use of monitors, and standard office equipment.
• Ability to meet physical and environmental job requirements in compliance with ADA and other employment regulations.

COMPENSATION

The salary range for this position is $70k - $80k. Specific offers take into account a candidate's education, experience and skills, as well as the candidate's work location and internal equity. This position is also eligible for health insurance, 401k and bonus opportunity.

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