Analyst, Claims (Remote)

About the role

tango is a leader in the home health management industry and is preparing for significant growth! Our mission is to deliver innovative, home-based, post-acute solutions through proprietary technology and proven processes. We partner with health plans to provide a comprehensive suite of products and services designed to manage the total cost of care.

The Claims Analyst is responsible for processing complex healthcare claims in accordance with internal policies, provider contracts, and applicable regulations. This role requires analytical expertise, thorough knowledge of reimbursement procedures, and a collaborative approach to resolving claim issues and supporting provider education efforts.

Responsibilities

• Reviews, processes and verifies insurance claims to ensure compliance with policy terms and regulatory requirements.
• Confirms reimbursement accuracy upon claims processing per Provider Contracts or SCA/LOA agreements.
• Analyzes claims EOP pend/denial codes and troubleshoots why claim did not pass business requirements.
• Collaborates with Customer Service Analysts to educate/re-educate providers on clean claim requirements.
• Meets Claims productivity standards (Quantity/Quality) consistently and self‑sufficiently.
• Supports ad‑hoc reporting needs including Auth/Claims Mismatch Files, Eligibility, Network requests for claims data, etc.
• Applies/retrains knowledge of coding to determine if claim should be denied or approved per claims policies.
• Reviews documentation and analyzes submitted claims data with an average of 95% accuracy monthly.
• Escalates any system issues or roadblocks that prevent hitting claim metrics.
• Processes claims within Claims Policies at 95% accuracy and meeting productivity standards as outlined.
• Maintains thorough knowledge of EOB denial/pend codes, HIPPS, HCPCS and DX codes to process claims within regulations.
• Escalates all Provider Claim issues and systemic errors to ensure positive rapport with network Providers per PHCN/tango Claims Policies and Procedures.
• Possesses knowledge of Medicaid EVV verification process for accurate claims processing.
• Possesses knowledge of PDGM reimbursement processing for Medicare claims.
• Possesses knowledge of authorization process for accurate claims processing.
• Familiar with EDI claims/claims submission related to CMS requirements.

Requirements

• 3–5 years of direct experience minimum in Healthcare Insurance, Claims Adjudication and EDI requirements.
• In‑depth knowledge of Medicare/Medicaid claims processing and CMS regulations.
• Detailed knowledge of claims adjudication – medical coding; HIPPS, CPT and HCPCS codes.
• 1–3 years in revenue cycle management.
• In‑depth knowledge of eligibility, authorization process, skilled home health care procedures, and COB practices.
• Detailed knowledge of multiple benefit plan designs including In/Out of Network designs for DSNP, MA HMO, POS, PPO, etc.

Skills

• Beginner level Microsoft Office skills (PowerPoint, Word, Outlook).
• Intermediate level Microsoft Excel skills.
• Analytical, research, problem solving, and decision‑making skills.
• Ability to adjudicate 185+ claims a day.