Senior Claims Analyst

About the role

The Senior Claims Analyst performs highly complex and technical analysis for research, resolution, and recovery of health plan claims. The position handles departmental and project coordination for issue resolution and process improvement, ensuring systems, processes, and reports enable the Claims Administration department to meet internal and external benchmarks. This role also serves as a subject matter expert regarding claims-related policies and procedures.

Responsibilities

• Analyze highly complex claims and claim issues to ensure correct claims payment; partner with Claims Administration staff and health plan business partners for resolution.
• Identify trends and recommend solutions for errors identified through pre- and post-payment claim and recovery review.
• Assist department leadership to develop daily inventory plans based on available resources, priority, and timeliness requirements.
• Analyze provider correspondence and requests for review to determine correct outcomes and resolution; escalate high-priority/risk issues to leadership.
• Lead departmental projects and/or operational improvement initiatives.
• Assist in the examination, assessment, and business documentation of operations and procedures to ensure data integrity, security, and process optimization.
• Ensure adherence to state and federal compliance, reimbursement, and contract policies.
• Provide mentoring and coaching to team members; assist and provide feedback to less experienced staff; lead training efforts for new employees.
• Participate openly in team meetings, contributing ideas and suggestions to ensure departmental efficiency, quality, and teamwork.
• Maintain required compliance with privacy and confidentiality standards.
• Maintain or exceed all established standards for performance, quality, and timeliness.
• Demonstrate ethical business practices and personal actions adhering to all Health System and Health Plan policies and procedures.
• Assist with other related work responsibilities as requested.

Qualifications

• Any combination of education and experience that would likely provide the required knowledge, skills, and abilities is qualifying.
• Minimum five years professional experience in claims analysis, provider medical billing, or medical coding; Texas Medicaid experience preferred.
• Minimum two years professional experience with claim research, adjustment, and recovery; Texas Medicaid experience preferred.
• High school graduate or GED required.