Senior Claims Analyst - Remote

Welcome to a team of caring and passionate people who work each day to meet the needs of our members and clients. At Health Benefits, (a subsidiary of Health Care Service Corporation), you will be part of an organization committed to offering custom services to self-funded health benefits plans that manage costs – without compromising benefits – by offering innovative solutions, flexibility, transparency, and customer support. We are now a subsidiary of Health Care Service Corporation, the largest customer-owned insurance company in the United States and a strategic partner of Health Benefits since 2018, giving us access to increased national scale and support. This is an exciting time to join our team and enhance our culture that emphasizes caring, diversity and inclusion, mutual respect, collaboration, and service to our communities.

At Health Benefits, we value our diverse team of Senior Claim Analysts and we’re looking for new hires that want to learn and grow their careers with us! In this position, you will have the ability to work from home. You will also participate in a 6-week training class, with our new hires scheduled to begin on September 11, 2023. Our Trainers provide a detailed program to give you the knowledge and tools to be successful in your new role. Hours for the duration of training will be 8:00 am-4:00 pm CST, Mon-Fri and after training your hours will be 8:00 am - 4:00 pm CST, Mon-Fri.

This position includes a variety of claim administrative and technical tasks that support a Claim Department and/or outsourced vendor staff. The responsibilities of a Senior Claim Analyst may vary depending upon the needs of the Department. In addition to these tasks, the Senior Claims Analyst is responsible for all of the same tasks as a Claim Analyst including the accurate adjudication and processing of medical, dental, vision, or other related claims, including related correspondence and/or electronic inquiries for assigned groups. All claims and inquiries are handled according to the established plan documents, claim processing guidelines, and established total turnaround times. Also advise team members regarding claim processing procedures.

Key Accountabilities

• Support the management, monitoring, and tracking of performance in collaboration with the Supervisor
• Support the Claims reinsurance team, in the research and resolution of claims as assigned
• Research and respond to vendor reconciliation requests
• Resolve client, employee/member, or provider issues regarding escalated or complex claims
• Handle network referrals as well as PPO repricing disputes
• Accurately handle correspondence, claims, and referrals in the established timeframes and/or performance guarantees
• Handle complex or technical claim adjudication using internal and external resources as needed, e.g. transplants, experimental & investigational, chemotherapy, etc
• Handle claim referrals, including pre-determinations, using internal and external resources as needed. Advice Claim Analysts and/or vendor regarding claim processing
• Provide mentoring and coaching
• Determine benefit coverage based on clinical edits, plan documents/booklets, benefit reference documents, Claim Reference Manuals and claims-related memoranda, and reports
• Other duties as needed/assigned
• Review and release over-authority claims up to limit specified by corporate policy
• Review, analyze and interpret claim forms and related documents
• Assist Supervisor in documenting processes for analysts
• Appropriately investigate, pend and refer claims based on claim procedures and guidelines
• Mentor and assist with onboarding new Analysts, including the oversight of work

Job Qualifications

• Minimum three years of medical claim processing experience
• Self-directed individual who works well with minimal supervision
• Flexible; open to continued process improvement
• Ability to effectively deal with problems in varying situations and reach resolution
• Ability to read, analyze and interpret documents and Summary Plan Descriptions (SPDs)
• High School diploma or GED equivalent
• Good leadership, organizational and interpersonal skills
• Excellent verbal and written communication skills
• Ability to learn new/proprietary systems, to adapt to various system platforms, and to effectively use MS Excel/Word
• Demonstrated critical thinking skills
• Ability to work in a fast-paced, customer service & production driven environment
• Ability to work effectively with employees/members, providers, clients and differing levels of co-workers including Client Managers and all levels of staff

At Health Benefits, you will be part of an organization committed to offering meaningful benefits to our associates to support their life outside of work. From health and wellness benefits, 401(k) savings plan, a minimum of 15 days’ of paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, new parent paid leave, tuition reimbursement, plus other incentives, we offer a robust total rewards package for full-time associates.

The compensation range for this full-time Senior Claims Analyst role is $17.28 - $32.44. The salary offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan.

All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, sexual orientation, sexual identity, age, veteran or disability.

Required Skills

Required Experience