Senior Claims Coding Analyst

About the role

The Senior Claims Coding Analyst – Dispute Triage & Optimization serves as a coding subject matter expert and triage coordinator responsible for optimizing the disposition of provider disputes across populations of claim scenarios. The Senior Analyst uses coding expertise and claims data to identify dispute patterns, determine root causes, and recommend the most effective resolution approach, including individual review, standardized disposition, automation, configuration changes, policy clarification, or provider education. The role is accountable for improving cost per dispute and total administrative cost per member while maintaining payment accuracy, regulatory compliance, and a positive provider and consumer experience. The Senior Analyst independently resolves complex coding and payment issues, supports dispute prevention efforts, and provides guidance to Claims Coding Analysts.

Responsibilities

• Serves as a triage coordinator for provider disputes, determining the appropriate resolution pathway based on coding complexity, root cause, financial impact, compliance requirements, and administrative cost.
• Analyzes dispute populations to identify trends, root causes, and opportunities for standardized, automated, or lower-cost resolution.
• Performs independent coding analysis and dispositions complex claims, disputes, and appeals using Healthfirst payment policy and applicable coding and regulatory guidelines.
• Identifies high-volume and high-cost dispute scenarios and develops population-level solutions to reduce repeat disputes and unnecessary manual review.
• Recommends and supports changes to claims edits, configuration, payment policies, workflows, automation, and provider education based on dispute findings.
• Partners with Claims, Provider Operations, Configuration, Technology, Payment Integrity, and other stakeholders to implement dispute resolution and prevention strategies.