Intermediate Claims Analyst

Summary / Objective:

The Claims Analyst role ensures the integrity and accuracy of claims processing across the organization. This position is essential for maintaining compliance, supporting operational efficiency, and delivering positive experience for members and providers. While responsibilities vary by level, all Claims Analysts share a commitment to precision, regulatory adherence, and collaboration to achieve timely and accurate outcomes.

The Intermediate Claims Analyst manages moderately complex claims, ensuring accurate evaluation and resolution while delivering excellent customer service. This role requires analytical skills, sound judgment, and the ability to handle a higher volume of claims independently. The Intermediate Analyst also investigates discrepancies, resolves escalated issues, and identifies patterns in claim errors to recommend process improvements. Maintaining accurate records for compliance and supporting audits are key expectations at this level.

Key Responsibilities:

• Analyze and process claims with moderate complexity, ensuring timely and accurate resolution.
• Conduct investigations, including reviewing policy terms, benefit structures, and supporting documentation.
• Identify discrepancies and recommend corrective actions to reduce errors and improve efficiency.
• Communicate with stakeholders to clarify details and resolve escalated issues.
• Provide guidance to Associate Analysts and assist in onboarding and training activities.
• Ensure compliance with regulatory standards and internal policies; maintain documentation for audits.
• Contribute to process improvement initiatives by identifying patterns and recommending workflow enhancements.

Essential Functions:

(Performed at varying levels of complexity depending on position)

• Key encounters, specialty claims, and facility claims, with a high degree of accuracy within compliance deadlines.
• Perform claims evaluation and investigation to support customer service as needed.
• Communicate efficiently with members, providers, and internal teams regarding claim benefit questions or information.
• Exceed customer expectations by providing professional and personalized service.
• Process incoming and outgoing mail for the Claims department.
• Scan, organize, and manage claim-related documents to ensure accurate recordkeeping and audit readiness.
• Maintain document management systems, ensuring all claim files are properly stored, retrievable, and compliant with company policies.
• Track claims financial transactions, including payments, refunds, and recoups, with accuracy and within compliance deadlines.
• Prepare, process, and distribute claim checks; maintain check processing files.
• Research, process, and resolve disputes, recoupments, and refund requests.
• Serve as a customer service representative for members, physicians, and vendors, including phone, fax, mail, and follow-up on issues.
• Adjudicate claims in accordance with Medicare, Medicare Advantage, and department guidelines/policies.
• Provide suggestions to streamline processes based on daily activities.
• Support strategic plans and implement new policies, procedures, and company initiatives as assigned.
• Build and leverage cross-functional collaborative relationships to foster teamwork and achieve company goals.
• Review assigned areas of responsibility and suggest enhancements to services and products.
• Continued education by staying informed of industry trends and actively participating in company-provided training.
• Ensure compliance with PSW policies and procedures, with special emphasis on HIPAA requirements.

Knowledge/Skills/Abilities:

• Sets a positive example through professionalism and proactive problem-solving.
• Strong interpersonal skills to build relationships across departments and with external stakeholders.
• Effective verbal and written communication for resolving moderately complex issues.
• Solid organizational and time management skills to handle higher claim volumes independently.
• Ability to prioritize tasks, make sound decisions, and assist team members when needed.
• Advanced computer proficiency, including maintaining records in compliance with regulatory standards.

Required Education and/or Work Experience:

• Associate degree or equivalent experience in lieu of education required.
• 2–4 years of experience in claims processing or billing within a high-volume, accuracy-driven environment, or an equivalent combination of education and experience.
• Knowledge of Medicare or Medicare Advantage payment rules, fee schedules, and CMS regulatory compliance standards.
• Proven ability to manage moderately complex claims with strong attention to detail and accuracy.
• Familiarity with claims payment or billing and coding structure.
• Excellent analytical, problem-solving, and communication skills.
• Advanced certification such as CPC (Certified Professional Coder) or AHIP (America's Health Insurance Plans).

Preferred Education and/or Work Experience:

• Bachelor's degree or higher in business, healthcare administration, or related field.
• Advanced certifications in health insurance and compliance (e.g., AHIMA's CCS – Certified Coding Specialist or AAPC's CPC – Certified Professional Coder)
• Prior experience mentoring, training, or leading team members in claims processing, analysis, or adjudication.
• Demonstrated expertise in Medicare and Medicare Advantage compliance, including CMS regulatory standards and fee schedules.
• Hands-on experience with Cedar Gate EzCap or other enterprise-level claims processing tools.
• Experience with claims system configuration or automation logic (e.g., EZ-CAP or similar platforms).
• Strong analytical skills with proven ability to identify trends, recommend process improvements, and support risk management initiatives.
• Proficiency in data analysis tools and reporting for compliance and operational performance.
• Knowledge of industry best practices for claims adjudication and operational efficiency.
• Ability to collaborate cross-functionally with IT, compliance, finance, and operations teams.

Required Certificates, Licenses and Registrations:

• Advanced certification such as CPC (Certified Professional Coder) or AHIP (America's Health Insurance Plans) at the intermediate and senior level.

PSW does not typically hire new employees near the top of the salary range.

Benefits:

401(k)

401(k) matching

Dental insurance

Disability insurance

Flexible Spending Account (FSA)

Health Savings Account (HSA)

Health insurance

Life insurance

Paid time off

Tuition reimbursement

Vision insurance