Sr. Claims Analyst, Health and Risk Solutions

About the role

The Health and Risk Solutions Senior Claim Analyst serves as the highest level of technical expertise within the claims unit, leading the evaluation, investigation, negotiation, and settlement of complex claims and risk matters. In this role, you will help ensure legitimate claims and benefits are paid accurately and efficiently while balancing the interests of policy owners and the company. You will also play a key role in managing internal and external relationships, supporting new hire training, and coaching and mentoring Health and Risk Solutions Claim Analysts and Overpayment Specialists.

How you will contribute

• Manage overall claim risk, including pay/deny decisions, by applying contract language and developing action plans for complex Stop Loss claims.
• Coordinate complex claims activity across multiple parties, ensuring actions are appropriately sequenced and completed on time.
• Identify and monitor evolving medical and prescription drug trends, applying responsive case management strategies.
• Apply deep knowledge of complex claim practices and legal precedents to resolve unique or precedent-setting matters.
• Partner with peers and leadership to establish, refine, and institutionalize claims policies and best practices.
• Manage communications with policyholders, administrators, top-tier brokers, sales representatives, vendors, and internal partners.
• Coach and mentor less experienced team members, including developing learning modules and supporting technical development.
• Train new hires on accurate claim reimbursement practices and client service expectations.
• Manage monthly accommodation advance payment claims and assigned claim blocks while maintaining turnaround times and service quality.
• Stay current on industry practices and contribute to evolving claims management techniques.
• Serve as a departmental leader and subject matter expert, including participating in field visits and settlement discussions.

What you will bring with you

• Ability to work with a diverse range of people.
• 7+ years of experience handling complex claims, Medical Stop Loss or complex Medical Claims.
• Deep knowledge of complex claim practices, legal precedents, claims accounting, and applicable state and federal healthcare legislation.
• Strong judgment, initiative, and consultative decision-making, with the ability to influence recommendations that may impact company operations.
• Recognized subject matter expertise, including industry involvement through peer presentations, panels, or professional forums.
• Established industry network to exchange ideas, trends, and emerging claim management techniques.
• Excellent communication, negotiation, and influencing skills, including the ability to navigate conflict and align stakeholders.
• Ability to draft clear, compliant written correspondence that meets guidelines and is easily understood by the recipient.
• Creative, resourceful problem-solving skills, including the ability to develop action plans and resolve complex matters using specialized resources or claims management techniques.

Pay

$68,200-$102,300