Job Title

Senior Claims Analyst

Status: Non-Exempt

Why This Role Is Important:

In the TPA world, precision, compliance, and cost control are everything. As a Senior Claims Analyst, you’re not just processing claims—you’re applying plan documents, regulatory standards, and sound judgment to every line item. You will play a vital role in protecting plan assets and ensuring members and providers are treated fairly. Our clients depend on us for accuracy, integrity, and accountability, and that starts with you.

Essential Functions:

Claims Processing, Review and Quality Assurance

Process complex medical in accordance with plan documents, including PPO, HDHP, self-funded, and reference-based pricing plans.
Interpret and apply Summary Plan Descriptions (SPDs) and employer-specific plan designs.
Ensure claims are adjudicated according to plan eligibility, network discounts, medical necessity, COB, and applicable exclusions or limitations.
Review provider billing for inappropriate billing practices.
Apply Usual, Customary & Reasonable (UCR) guidelines or reference-based pricing (RBP) where applicable.
Process dental and vision claims
Work cross-functionally with customer service, eligibility, compliance, and account management teams to resolve complex claims issues.
Assist with department special projects.
Collaborate with external vendors and partners, attend meetings, and provide input when necessary.
Assist with providing reports on outsourced claims processing, address inquiries, and provide feedback.

Non Essential Functions:

Additional tasks as requested by management.

Required Qualifications:

Required:

Minimum 5 years of experience working as a Claims Analyst for a Third-Party Administrator (TPA)
Experience with processing dental and vision claims
Strong knowledge of claims auditing and appeals
Strong understanding of ERISA, HIPAA, COB, FSA, HRA, and other relevant compliance requirements

Strong knowledge of medical coding systems (ICD-10, CPT, HCPCS) and healthcare billing practices
Excellent analytical and investigative skills
High attention to detail and accuracy
Ability to interpret complex plan documents and benefit designs
Proficiency with claims adjudication software
Clear written and verbal communication
Strong time management and prioritization skills
Ability to work well and be supportive in a team-oriented environment.
Commitment to confidentiality and ethical standards

Preferred:

Associate’s degree or higher in a healthcare-related field
Experience with reference-based pricing or value-based plan models
Familiarity with stop-loss processes and large claims reporting

Working Conditions:

This position follows a remote or hybrid schedule

Compensation Range:

$24/hr – $28/hr, based on experience and qualifications

Requirements

Required:

Minimum 5 years of experience working as a Claims Analyst for a Third-Party Administrator (TPA)
Experience with processing dental and vision claims
Strong knowledge of claims auditing and appeals
Strong understanding of ERISA, HIPAA, COB, FSA, HRA, and other relevant compliance requirements

Strong knowledge of medical coding systems (ICD-10, CPT, HCPCS) and healthcare billing practices
Excellent analytical and investigative skills
High attention to detail and accuracy
Ability to interpret complex plan documents and benefit designs
Proficiency with claims adjudication software
Clear written and verbal communication
Strong time management and prioritization skills
Ability to work well and be supportive in a team-oriented environment.
Commitment to confidentiality and ethical standards

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