Senior Analyst, Claims Research

Senior Claims Research Analyst

The Senior Claims Research Analyst provides senior-level support for claims processing and claims research. The Sr. Analyst, Claims Research serves as a senior-level subject matter expert in claims operations and research, leading the most complex and high-priority claims projects. This role involves advanced root cause analysis, regulatory interpretation, project management, and strategic coordination across multiple departments to resolve systemic claims processing issues. The Sr. Analyst provides thought leadership, develops remediation strategies, and ensures timely and accurate project execution, all while driving continuous improvement in claims performance and compliance. Additionally, the Sr. Analyst will represent the organization internally and externally in meetings, serving as a key liaison to communicate findings and resolution plans effectively.

Job Duties:

• Uses advanced analytical skills to conduct research and analysis for issues, requests, and inquiries of high priority claims projects
• Assists with reducing re-work by identifying and remediating claims processing issues
• Locate and interpret regulatory and contractual requirements
• Expertly tailors existing reports or available data to meet the needs of the claims project
• Evaluates claims using standard principles and applicable state specific policies and regulations to identify claims processing error
• Act as a senior claims subject matter expert, advising on complex claims issues and ensuring compliance with regulatory and contractual requirements
• Leads and manages major claims research projects of considerable complexity, initiated through provider inquiries, complaints, or internal audits
• Conducts advanced root cause analysis to identify and resolve systemic claims processing errors, collaborating with multiple departments to define and implement long-term solutions
• Interprets regulatory and contractual requirements to ensure compliance in claims adjudication and remediation processes
• Develops, tracks, and/or monitors remediation plans, ensuring claims reprocessing projects are completed accurately and on time
• Provides in-depth analysis and insights to leadership and operational teams, presenting findings, progress updates, and results in a clear and actionable format
• Takes the lead in provider meetings, when applicable, clearly communicating findings, proposed solutions, and status updates while maintaining a professional and collaborative approach
• Proactively identifies and recommends updates to policies, SOPs, and job aids to improve claims quality and efficiency
• Collaborates with external departments and leadership to define claims requirements and ensure alignment with organizational goals

Job Qualifications:

Required Qualifications:

• 5+ years of experience in medical claims processing, research, or a related field
• Demonstrated expertise in regulatory and contractual claims requirements, root cause analysis, and project management
• Advanced knowledge of medical billing codes and claims adjudication processes
• Strong analytical, organizational, and problem-solving skills
• Proficiency in claims management systems and data analysis tools
• Excellent communication skills, with the ability to tailor complex information for diverse audiences, including executive leadership and providers
• Proven ability to manage multiple projects, prioritize tasks, and meet tight deadlines in a fast-paced environment
• Microsoft office suite/applicable software program(s) proficiency

Preferred Qualifications:

• Bachelor's Degree or equivalent combination of education and experience
• Project management
• Expert in Excel and PowerPoint
• Familiarity with systems used to manage claims inquiries and adjustment requests