Senior Claims Analyst

Required Skills & Experience

3+ years of managed care/payer operations experience, ideally supporting Medicaid and/or Medicare. Strong claims triage and investigation experience, including escalations, claims adjudication, troubleshooting, and determining the appropriate resolution path. Root-cause and impact analysis experience, with the ability to identify why claims are processing incorrectly and whether the issue affects multiple claims/providers. Hands-on Facets experience, ideally researching claims, provider setup/configuration, benefits, reimbursement, or adjudication issues.

Nice to Have Skills & Experience

Provider setup/configuration experience Medical coding knowledge: CPT, HCPCS, ICD-10 Cactus or Choreo experience SQL or advanced Excel/reporting skills

Job Description

The Senior Claims Analyst will serve as the initial triage and research point for complex healthcare claims and provider-related escalations within a managed care environment. This individual will review incoming operational issues, assess urgency and business impact, conduct preliminary claims research, identify potential root causes, gather supporting documentation, and determine the appropriate next step or resolution path. The ideal candidate has strong Medicaid/Medicare managed care experience, hands-on claims adjudication and troubleshooting experience, and the ability to quickly determine whether an issue is related to claims processing, provider setup, configuration, coding, reimbursement, benefits, or another operational area.

Key Responsibilities:

Triage incoming claims, provider, and operational escalations to determine priority, impact, and next steps. Research complex claims to identify denials, payment issues, trends, and potential root causes. Use Facets and other payer systems to investigate claims, provider setup, benefits, and configuration issues. Determine whether issues are isolated or systemic across multiple claims or providers. Document findings and route/escalate issues to the appropriate operational team for resolution. Partner with providers, market teams, Claims, Configuration, Network, and other teams to resolve issues and improve processes.