Claims Analyst / Senior Claims Processor

Pay Range: $23-$28 per hour
Schedule: Monday-Friday, 8:30 a.m. - 4:30 p.m.
Location: Onsite (parking provided)

About the Role

We're looking for an experienced Claims Analyst to join our team and play a key role in ensuring accurate, timely processing of healthcare claims. This position is ideal for someone who enjoys problem-solving, working with complex benefit plans, and collaborating with both internal teams and external partners.

What You'll Do

• Process paper and electronic professional, facility, ancillary, and out-of-state (Blue Card®) claims, including pay, deny, and pend decisions.
• Research, resolve, and adjust claims by correcting allowances, recovering overpayments, and reprocessing previously paid or failed claims.
• Apply detailed benefit plan knowledge, including covered services, exclusions, coordination of benefits, and Medicare coordination.
• Identify and review claims related to fraud, waste, abuse, hospital-acquired conditions, Workers' Compensation, and Third-Party Liability, escalating when appropriate.
• Recognize claims requiring clinical review, request medical records, and refer cases to the Claims Manager.
• Communicate professionally with members and providers to resolve inquiries, follow up on pended claims, and complete corrections or adjustments.
• Provide backup support to Member Services and step in as a Member Services Representative when needed.
• Consistently meet productivity, quality, and schedule adherence standards.
• Follow internal policies and procedures while contributing to special projects and process improvements.

What We're Looking For

• High school diploma or GED required.
• 5+ years of recent health claims processing experience (10+ years preferred).
• Experience processing group medical claims or healthcare benefits from a payer or provider perspective.
• Strong knowledge of medical terminology, billing practices, CPT, ICD-9/ICD-10, HCPCS, DRG, and revenue codes.
• Solid understanding of benefit plans, coordination of benefits, exclusions, and third-party liability.
• Excellent analytical, organizational, and problem-solving skills with strong attention to detail.
• Proficiency with Windows-based applications and the ability to learn complex claims systems.
• Clear, professional verbal and written communication skills with a strong customer-service mindset.
• Ability to manage multiple priorities, work under pressure, and collaborate effectively within a team.