Senior Claims Analyst

Job Description

Serve as a subject matter expert for IT systems as well as professional, institutional, and ancillary claims processing. Support claims adjudication rules, benefit configuration, edits, pricing, and payment logic. Interpret CMS regulations (e.g., clean claim standards, timely payment, Medicare Advantage requirements) and ensure system alignment. Partner with Claims leadership on operational issues, root cause analysis, and corrective actions.

IT & Systems Integration

Act as the primary bridge between Claims Operations and IT teams. Support claims system implementations, upgrades, and migrations (e.g., UAT planning, test scenarios, defect tracking). Validate system configuration changes affecting claims adjudication. Assist with system troubleshooting, claim loading issues, and configuration defects. Review and validate end-to-end claims workflows across multiple systems.

Data & EDI

Support EDI transactions including 837 (P/I), 835 (ERA), 277, and related file exchanges. Validate inbound and outbound data extracts, reports, and file transmissions. Ensure data accuracy between claims systems, downstream vendors, and reporting tools. Coordinate with IT and vendors on SFTP processes, naming conventions, and file ingestion issues.

Vendor & Cross-Functional Collaboration

Work closely with external vendors, clearinghouses, and delegated entities on technical and operational matters. Participate in status meetings, UAT reviews, and issue resolution with vendors. Provide clear documentation and guidance to support consistent system usage.

Documentation & Governance

Aid in the development and maintenance of policies, procedures, job aids, and system documentation. Ensure documentation is audit-ready and CMS-compliant. Support internal and external audits related to claims systems and data integrity.

Requirements

• Minimum Qualifications: 5+ years of healthcare claims operations experience, including Medicare Advantage. Bachelor’s degree or equivalent in Healthcare Administration or related field. Strong working knowledge of claims systems and how claims are configured, adjudicated, and paid. Hands-on experience with claims IT functions, system testing, or system implementations. Solid understanding of EDI healthcare transactions (837/835 required). Experience working as a liaison between business and IT teams. Strong analytical, troubleshooting, and documentation skills. Ability to translate business requirements into technical requirements and vice versa. Prior experience in a health plan or managed care environment.
• Preferred Qualifications: Experience supporting claims system implementations or migrations. Familiarity with delegated claims environments and vendor oversight. Experience in UAT planning, test case development, and defect management. Knowledge of CMS regulations related to claims processing and data submissions.

Core Competencies

• Claims Adjudication & Compliance
• Claims Systems Configuration
• EDI & Data Integration
• UAT & System Testing
• Cross-Functional Communication
• Vendor Management
• Audit & Documentation Readiness

Supervisory Responsibilities

This job has no direct supervisory responsibilities.

Benefits

• 401(k)
• Paid time off (vacation, holiday, sick leave)
• Health insurance
• Dental Insurance
• Vision Insurance
• Life Insurance

Schedule

Full-time onsite (100% in-office)

Hours of operation

9am – 6pm Standard business hours Monday to Friday/weekends as needed

Occasional travel

May be required for meetings and training sessions.

Physical Demands

Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.