[Hiring] Claims Analyst/Examiner @Advanced Medical Management

Role Description

The Claims Analyst / Examiner is responsible for the accurate review, analysis, adjudication support, and investigation of professional, institutional, and ancillary claims within a Full-Risk Value-Based Care IPA/MSO environment. This role goes beyond traditional claims examination and requires strong analytical capability in payment integrity, claims variance analysis, overpayment and underpayment detection, and root-cause validation against EZCAP system configuration.
• Claims Review and Examination
• Review and analyze incoming claims for completeness, accuracy, eligibility, authorization requirements, coding appropriateness, and adjudication readiness.
• Examine professional, institutional, outpatient, ancillary, and capitated encounter-related claims.
• Investigate pended, denied, adjusted, and suspended claims.
• Validate claims against member eligibility, provider status, contract terms, benefit coverage, referral/authorization requirements, and claims submission rules.
• Support accurate application of payment methodology based on claim type, provider contract, fee schedule, capitation carve-out, and delegated responsibility.
• Ensure claims are processed in alignment with turnaround time requirements, payment policies, and internal service standards.
• Payment Integrity Analysis
• Perform detailed reviews of paid claims to identify overpayments, underpayments, duplicate payments, incorrect denials, contract variances, and payment leakage.
• Analyze payment outcomes for alignment with fee schedules, contracted reimbursement logic, CMS/CPT/HCPCS coding rules, modifiers, benefit plans, and delegated responsibility.
• Investigate discrepancies between expected and actual payment results.
• Identify trends and recurring payment issues impacting claims expense, provider abrasion, or financial leakage.
• Support pre-payment and post-payment audit activities.
• Partner with Finance and leadership on recoveries, offset opportunities, overpayment identification, and underpayment remediation.
• Assist in development of audit logs, tracking reports, and claims issue summaries.
• EZCAP Configuration Crosswalk and Root Cause Analysis
• Review claims outcomes against EZCAP configuration components.
• Determine whether payment issues are caused by various factors.
• Escalate configuration-related findings clearly and accurately.
• Participate in validation testing for configuration changes.
• Help ensure contract language and delegated responsibility are translated correctly into executable EZCAP claims logic.
• Claims Issue Resolution and Operational Support
• Research provider disputes, claim reconsiderations, payment complaints, and escalated claims inquiries.
• Prepare clear written summaries of findings, root cause, and recommended corrective action.
• Work closely with various teams to resolve complex claims issues.
• Support adjustment requests and reprocessing recommendations.
• Assist in resolution of recurring claim errors.
• Reporting and Data Analysis
• Prepare recurring and ad hoc analyses of claims payment trends, error patterns, denial rates, adjustment activity, overpayment/underpayment findings, and operational pain points.
• Build or support reporting that highlights financial leakage, payment variance trends, and claims adjudication opportunities.
• Monitor claims metrics related to payment accuracy, pends, inventory aging, adjustment volumes, provider disputes, and denial categories.
• Identify actionable trends and recommend process or configuration improvements.
• Support audit readiness by maintaining documentation, case summaries, and supporting evidence.
• Compliance and Regulatory Adherence
• Ensure claims review activities comply with applicable health plan requirements, CMS guidance, state prompt-pay regulations, delegation requirements, and internal policies.
• Maintain strict confidentiality and compliance with HIPAA and all applicable privacy and security policies.
• Support accurate processing consistent with contractual obligations, regulatory standards, and audit expectations.
• Participate in internal and external audit support activities.
• Cross-Functional Collaboration
• Partner with various teams to resolve claims and payment integrity issues.
• Communicate issues with clarity.
• Contribute to process improvement initiatives.
• Serve as a subject matter contributor for workflows involving claims analysis, payment integrity, and configuration validation.

Qualifications
• Bachelor’s degree in Healthcare Administration, Business, Finance, or related field preferred.
• Minimum 3–5 years of progressive experience in healthcare claims operations, claims examination, payment integrity, claims auditing, or claims analysis.
• Strong experience in IPA, MSO, managed care, health plan, delegated model, or Medicare Advantage claims environments preferred.
• Direct experience using EZCAP required or strongly preferred.
• Demonstrated experience reviewing claims against DOFR, fee schedules, benefits, provider contracts, and authorization logic strongly preferred.
• Experience identifying overpayments, underpayments, and claims payment discrepancies required.

Requirements
• Strong understanding of the full claims lifecycle, including intake, adjudication, denial logic, payment methodology, adjustments, and dispute resolution.
• Strong knowledge of professional and institutional claims processing concepts.
• Familiarity with CMS, Medicare Advantage, managed care, delegated models, and full-risk reimbursement structures.
• Working knowledge of CPT / HCPCS / ICD-10 coding, modifiers, authorization and referral workflows, claims edits, provider contract reimbursement structures, fee schedules, and fee set maintenance concepts.
• Strong understanding of DOFR interpretation and how financial responsibility is operationalized in claims adjudication.
• Strong understanding of payment integrity principles.
• Proficiency in EZCAP claims inquiry and configuration review highly preferred.
• Strong experience with Excel, including filtering, pivot tables, v-lookups/x-lookups, and claims variance analysis.
• Strong written and verbal communication skills.

Benefits
• Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.
• Wellness Made Affordable: Discounted vision and dental premiums.
• Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
• Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays.
• Career Development: Tuition reimbursement to support your education and growth.