Claims Analyst

Description:

JOB SUMMARY

The Claims Analyst supports the Claims Department through regulatory reporting, claims data analysis, compliance monitoring, audit support, and operational reporting within a management services organization (MSO). This role analyzes claims-related data and operational results to identify trends, monitor timeliness and compliance, support regulatory submissions, and assist the department in meeting internal and external requirements. The Analyst prepares accurate reports, researches discrepancies, supports member denial and payment-related processes, and contributes to process improvements that promote efficient and compliant claims operations.

Requirements:

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: Associate’s degree or equivalent combination of education and relevant work experience.

Experience

Minimum: At least three years of healthcare claims operations, claims regulatory compliance, claims reporting, or related managed care experience. Experience preparing regulatory and operational reports, analyzing claims data, researching discrepancies, and working with claims processing systems.

Preferred: Five or more years of progressively responsible healthcare claims, regulatory compliance, reporting, or data analysis experience. Experience with ODAG, Part C, monthly timeliness reporting, member denials, health plan audits, check runs, policies and procedures, Tapestry, EZ-Cap, Microsoft Excel, and Microsoft Word. Experience in an MSO, IPA, health plan, or delegated managed care environment.
Any combination of educational and work experience equivalent to the stated minimum requirements would qualify for consideration.

Skills, Knowledge & Abilities

• Strong knowledge of healthcare claims processing, claims operations, and regulatory compliance requirements.
• Ability to prepare, validate, reconcile, and analyze claims-related regulatory and operational reports.
• Proficiency with Microsoft Excel and Microsoft Word; experience with Tapestry and EZ-Cap.
• Knowledge of ODAG, Part C, monthly timeliness reporting, member denials, and related claims compliance measures.
• Strong analytical and problem-solving skills with the ability to identify trends, discrepancies, and compliance concerns.
• Ability to support health plan and regulatory audits with accurate data and documentation.
• Ability to develop and maintain policies, procedures, reports, and supporting documentation.
• Strong attention to detail, organization, accuracy, and recurring deadlines.
• Effective written and verbal communication skills.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical demands described here are represented by those that must be met by an employee to successfully perform the essential functions of this job. Work is primarily performed in an office or hybrid office environment and involves prolonged periods of sitting, computer use, and data review. The role requires sustained concentration, analytical thinking, and attention to detail to ensure claims accuracy and regulatory compliance. Occasional lifting of materials up to approximately 10–20 pounds may be required. The position may require extended work hours or weekend work to meet operational and regulatory deadlines.

PAY RANGE

$33.65 - $38.46 / hourly