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Claims Operations Analyst
EmpiRx Health
Montvale, USA
Full-time
Entry · 1+ years experience
Onsite
Discovered 1 weeks ago
Microsoft Office SuiteSQL
Free
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Key Skills for This Role
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- Investigate and resolve complex claim, eligibility, and accumulator issues within service level agreements, ensuring issues are researched and documented according to departmental & enterprise standards.
- Conduct adaptable root cause analysis to identify short-term and long-term fixes and improvements to specific or systemic problems.
- Partner with technology, client services, customer service, finance, & privacy / legal / compliance teams to improve solution design and overall operational effectiveness.
- Monitor claims data on an ongoing basis to identify adverse or actionable trends related to claim issues, including errors with eligibility and accumulator integration.
- Execute the processing of direct member reimbursement requests.
- Coordinate with relevant departments to address and process subrogation claims effectively.
- Maintain detailed records of all manual claims processed.
- Proactive ownership of documentation materials related to benefit plan design while ensuring accuracy and accessibility for customers and stakeholders.
- 1–2 years of experience in pharmacy benefit administration, operations, or related areas.
- Strong attention to detail, organizational skills, and ability to manage multiple priorities.
- Bachelor’s degree or equivalent experience.
- Demonstrated experience in issue management and problem resolution.
- Strong analytical skills with ability to interpret data, identify trends / outliers, and diagnose potential issues.
- Prior experience with eligibility and accumulator data.
- Prior experience with claims adjudication platforms.
- Familiarity with direct reimbursement processes and related systems.
- Excellent written and verbal communication skills, with a focus on member and client satisfaction.
- Technical proficiency and aptitude
- Proficiency in Microsoft Office Suite, primarily Excel.
- Experience using SQL to perform data investigation and solution design.
- Experience with change control methodologies to aid issue resolution.
- Experience with personalized medicine or precision-based solutions .
- Understanding of payer, provider, or employer market dynamics .
- Experience designing solutions for whole-person care or population health strategies .
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