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 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 analyst independently resolves complex coding and payment issues, supports dispute prevention efforts, and provides guidance to Claims Coding Analysts.

Responsibilities

• Serve 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.
• Analyze dispute populations to identify trends, root causes, and opportunities for standardized, automated, or lower‑cost resolution.
• Perform independent coding analysis and disposition of complex claims, disputes, and appeals using Healthfirst payment policy and applicable coding and regulatory guidelines.
• Identify high‑volume and high‑cost dispute scenarios and develop population‑level solutions to reduce repeat disputes and unnecessary manual review.
• Recommend and support changes to claims edits, configuration, payment policies, workflows, automation, and provider education based on dispute findings.
• Partner with Claims, Provider Operations, Configuration, Technology, Payment Integrity, and other stakeholders to implement dispute resolution and prevention strategies.
• Monitor dispute performance, including volume, overturn and repeat rates, turnaround time, administrative cost, and resolution outcomes.
• Serve as a coding and payment policy subject matter expert, interpreting CMS, NYSDOH, CPT, HCPCS, ICD‑10, AMA, and other applicable guidance.
• Review medical records as needed to determine appropriate coding and claim disposition.
• Clearly communicate coding and payment decisions to providers and internal stakeholders and participate in provider discussions as needed.
• Lead continuous improvement efforts focused on reducing avoidable disputes, improving provider and consumer experience, and lowering administrative expense.
• Provide day‑to‑day guidance and mentorship to Claims Coding Analysts.
• Perform additional duties and special projects as assigned.

Requirements

• Coding class completion and/or certification from AAPC or AHIMA, including CPC or equivalent.
• Previous professional coding and/or claims payment experience (both payer and provider side).
• Experience researching and applying coding guidelines to complex claims or provider disputes.
• Ability to independently analyze claims and disputes and make defensible coding and payment decisions.
• High school diploma or GED from an accredited institution.

Qualifications

• Bachelor’s degree in a related field (preferred).
• Payer and/or provider‑side coding or claims experience (preferred).
• Experience with provider disputes, claims operations, claims editing, claims configuration, or healthcare operations analytics (preferred).
• Consumer and/or provider experience, with an understanding of how claims and dispute decisions impact member and provider interactions (preferred).
• Experience analyzing claim or dispute populations to identify trends, root causes, and improvement opportunities (preferred).
• Understanding of operational measures including cost per dispute, administrative cost, turnaround time, productivity, automation, and quality (preferred).

Skills

• Strong analytical, critical‑thinking, problem‑solving, communication, and stakeholder‑management skills.
• Knowledge of anatomy, medical terminology, CPT, HCPCS, ICD‑10, CMS, and New York State coding and payment requirements.

Benefits

• Medical coverage
• Dental coverage
• Vision coverage
• Incentive and recognition programs
• Life insurance
• 401k contributions (subject to eligibility)

Pay

Hiring range: Greater New York City Area (NY, NJ, CT residents): $83,100 – $120,360; All Other Locations (within approved locations): $73,400 – $109,225. Salary and related elements of compensation are contingent upon work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.