Analyst, Claims Research

Job Summary

Provides analyst support for claims research activities including reviewing and researching claims to ensure regulatory requirements are appropriately applied, identifying root-cause of processing errors through research and analysis, coordinating and engaging with appropriate departments, developing and tracking remediation plans, and monitoring claims reprocessing through resolution.

Essential Job Duties

Serves as claims subject matter expert - using analytical skills to conduct research and analysis to address issues, requests, and support high-priority claims inquiries and projects. Interprets and presents in-depth analysis of claims research findings and results to leadership and respective operations teams. Manages and leads major claims projects of considerable complexity and volume that may be initiated internally, or through provider inquiries / complaints, or legal requests. Assists with reducing rework by identifying and remediating claims processing issues. Locates and interprets claims-related regulatory and contractual requirements. Tailors existing reports and / or available data to meet the needs of claims projects. Evaluates claims using standard principles and applicable state-specific regulations to identify claims processing errors. Applies claims processing and technical knowledge to appropriately define a path for short / long-term systematic or operational fixes. Seeks to improve overall claims performance, and ensure claims are processed accurately and timely. Identifies claims requiring reprocessing or readjudication in a timely manner to ensure compliance. Works collaboratively with internal / external stakeholders to define claims requirements. Recommends updates to claims standard operating procedures (SOPs) and job aids to increase the quality and efficiency of claims processing. Fields claims questions from the operations team. Interprets, communicates, and presents, clear in-depth analysis of claims research results, root-cause analysis, remediation plans and fixes, overall progress, and status of impacted claims. Appropriately conveys claims-related information and tailors communication based on targeted audiences. Provides sufficient claims information to internal operations teams that communicate externally with providers and / or members. Collaborates with other functional teams on claims-related projects, and completes tasks within designated / accelerated timelines to minimize provider / member impacts and maintain compliance. Supports claims department initiatives to improve overall claims function efficiency.

Required Qualifications

At least 3 years of medical claims processing experience, or equivalent combination of relevant education and experience. Medical claims processing experience across multiple states, markets, and claim types. Knowledge of claims processing related to inpatient / outpatient facilities contracted with Medicare, Medicaid, and Marketplace government-sponsored programs. Data research and analysis skills. Organizational skills and attention to detail. Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines. Ability to work cross-collaboratively in a highly matrixed organization. Customer service skills. Effective verbal and written communication skills. Microsoft Office suite (including Excel), and applicable software programs proficiency.

Preferred Qualifications

Health care claims analysis experience. Project management experience.