Senior Medical Claims Professional

5 days ago


Monsey, New York, United States Health First Full time
Job Overview

We are seeking a highly skilled Senior Medical Claims Professional to join our team at Health First. In this role, you will be responsible for leading and delivering projects related to the development and configuration of new business, member benefits, and products, claims editing, reference data, and their enhancements.

Your Key Responsibilities:

  • Manage major claims configuration projects, including claims business rule setup and outlier management.
  • Interpret specific state and/or federal benefits, contracts, as well as additional business requirements and convert these terms to claims configuration setup parameters.
  • Translate complex high-level business requirements into functional requirements, specified to an appropriate level of detail.
  • Provide expert support to the claims configuration process and provide multifaceted triage and configuration troubleshooting assistance to other Healthfirst business areas.

About You:

  • You have experience utilizing analysis tools such as SQL, SAS, Alteryx, AWS, Python, and/or Tableau.
  • You are proficient in medical terminology, medical coding (CPT4, ICD9 or ICD10, and HCPCS), provider contract concepts, and common claims processing/resolution practices.
  • You have experience working with and leading cross-functional and level team members in claims configuration deliverables.

What We Offer:

  • A competitive salary range of $85,000 - $110,000 per year, depending on your level of experience.
  • Opportunities for professional growth and development.
  • A dynamic and supportive work environment.
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