SENIOR MEDICAL CLAIMS ANALYST.

Overview Quality-focused role owning team-level accuracy and complex case resolution. Responsible for leading quality initiatives, resolving escalated disputes, and mentoring junior staff while contributing to policy refinement.

Strategic Roles & Responsibilities Strategic % : 10%

Lead quality audit initiatives and implement corrective actions

Contribute to policy refinement based on claim pattern analysis

Mentor and develop junior staff capabilities

Operational Roles & Responsibilities Operational % : 90%

Lead quality audits for the claims team, analyzing root causes of errors

Implement corrective actions to reduce claim processing errors

Resolve escalated provider disputes involving moderate-complexity clinical determinations

Develop claim review checklists for high-frequency scenarios using trend data

Update and refine policies based on claim pattern analysis

Mentor junior staff on policy interpretation and dispute resolution

Conduct training sessions on complex claim scenarios

Maintain expertise in regulatory changes and industry best practices

Qualifications Bachelor degree in healthcare administration, business, or related field

Professional Certifications Required Professional certification (e.g., CPC, CPB) preferred

Years of Experience 4-6 years of progressive claims processing experience in healthcare or insurance

Languages

Accounts Receivable

Billing Investigations

Core Competencies

Integrity

Accountability

Cybersecurity

Person-Centered Care

Acknowledgement Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Supplemental Work / Experience / Education Information #J-18808-Ljbffr