Position Overview The Medical Claims Analyst is responsible for the accurate and timely adjudication of medical claims for self-funded employee benefit plans administered by I.E. Shaffer & Co. Working under the direction of the Welfare Claims Manager, the Medical Claims Analyst reviews, analyzes, and adjudicates medical claims in accordance with Plan Documents, Summary Plan Descriptions (SPDs), Trust Agreements, established claims procedures, industry standards, and applicable federal regulations. In addition to claims adjudication responsibilities, this position serves as a primary customer service resource for participants, providers, employers, and vendors by responding to telephone inquiries regarding claims, eligibility, and Plan benefits. The Medical Claims Analyst supports the delivery of exceptional service by accurately interpreting complex Plan provisions, exercising sound judgment, and maintaining high standards of quality, productivity, and professionalism. The level of responsibility assigned to this position will be based on qualifications, relevant experience, technical knowledge, demonstrated proficiency, complexity of assigned plans, and business needs. This role provides opportunities for professional growth and expanded responsibilities in claims adjudication, benefit interpretation, quality assurance, regulatory compliance, and customer service. Responsibilities Participant Customer Service Provide exceptional service to participants by responding to questions regarding claims, benefits, claim status, and Plan provisions. Research and resolve participant inquiries by reviewing claim information, explaining claim determinations, and providing clear guidance regarding Plan requirements. Maintain accurate documentation of telephone inquiries, correspondence, and claim activity within the claims administration system. Coordinate with internal departments, providers, employers, and vendors to support timely resolution of participant matters. Escalate complex issues to the Welfare Claims Manager when appropriate. Claims Adjudication Review, analyze, and adjudicate medical claims in accordance with Plan Documents, Summary Plan Descriptions, administrative procedures, and applicable regulations. Interpret benefit provisions to determine appropriate claim payment or denial. Evaluate claims for coding accuracy, completeness, eligibility, and appropriate reimbursement. Apply knowledge of ICD-10, CPT, HCPCS, DRG, Revenue Codes, Coordination of Benefits (COB), Medicare Secondary Payer requirements, and applicable claim processing guidelines. Utilize the Genelco Claims Administration System and other internal systems to process, research, and document claims activity. Research complex, suspended, and denied claims and obtain supporting documentation when needed. Process claim adjustments, corrections, and overpayment recoveries in accordance with established procedures. Identify claim trends, discrepancies, and opportunities for improvement and communicate findings to management. Maintain established quality, productivity, and turnaround time standards. Compliance & Operational Support Maintain confidentiality of participant information in accordance with HIPAA Privacy and Security requirements. Administer claims in compliance with Plan Documents, ERISA, HIPAA, Medicare, COBRA, ACA, and applicable regulations. Assist with quality assurance reviews, audits, and operational improvement initiatives. Maintain knowledge of industry coding updates, regulatory changes, and Plan amendments affecting claims administration. Collaborate with Enrollment, Eligibility, Account Management, Accounting, Information Technology, and other departments to support accurate and efficient claims administration. Participate in training, continuing education, and process improvement initiatives. Perform other duties and responsibilities as assigned. Professional Responsibilities Demonstrate accuracy, attention to detail, sound judgment, and ownership of assigned responsibilities. Manage workload effectively, prioritize competing responsibilities, and meet established deadlines. Communicate professionally and collaborate effectively with participants, providers, employers, vendors, and internal teams. Demonstrate initiative, adaptability, and commitment to continuous learning and professional growth. Maintain regular and dependable attendance while supporting departmental goals. Comply with company policies, confidentiality requirements, and applicable regulatory obligations. Core Competencies Technical Expertise & Functional Knowledge Demonstrates knowledge of medical claims adjudication, benefit interpretation, coding methodologies, claims systems, and applicable regulations while accurately applying Fund-specific Plan provisions. Quality & Accuracy Maintains exceptional attention to detail, follows established procedures, and consistently produces accurate, reliable, and compliant work. Customer Service Excellence Provides responsive, professional, and solutions-oriented service while effectively managing participant, provider, employer, and vendor interactions. Analytical Thinking & Problem Solving Analyzes complex claims information, researches issues, evaluates available documentation, and exercises sound judgment in making claim determinations. Communication & Collaboration Communicates clearly and professionally with participants, providers, clients, vendors, and internal departments while fostering positive working relationships. Organization & Productivity Effectively manages competing priorities, adapts to changing workloads, and consistently meets established deadlines and performance expectations. Accountability & Ownership Takes responsibility for assigned work, follows through on commitments, identifies opportunities for improvement, and demonstrates initiative. Professionalism & Integrity Maintains confidentiality, demonstrates ethical decision-making, and represents I.E. Shaffer & Co. with professionalism and integrity. Qualifications Required High school diploma or equivalent required; Associate's or Bachelor's degree preferred, or equivalent combination of education and relevant experience. Minimum of five (5) years of medical claims adjudication experience. Experience administering self-funded employer-sponsored health benefit plans. Demonstrated experience interpreting Plan Documents and Summary Plan Descriptions. Strong working knowledge of ICD-10, CPT, HCPCS, DRG, Revenue Codes, and medical claims coding standards. Working knowledge of Coordination of Benefits (COB), Medicare Secondary Payer requirements, HIPAA, and applicable federal claim processing regulations. Demonstrated experience handling a high volume of participant and provider telephone inquiries. Strong analytical, organizational, critical thinking, and problem-solving skills. Excellent written, verbal, and interpersonal communication skills. Ability to learn and accurately administer multiple employee benefit plans with varying eligibility requirements and benefit provisions. Proficiency with Microsoft Office applications and ability to quickly learn claims administration software. Preferred Experience administering Taft-Hartley (multiemployer) employee benefit plans. Experience using the Genelco Claims Administration System or comparable claims administration software. Knowledge of ERISA and self-funded employee benefit plan administration. CEBS coursework, professional claims certifications, or other employee benefits-related education. Bilingual language skills. About I.E. Shaffer & Co. Established in 1957, I.E. Shaffer & Co. is a 100% employee-owned third-party administrator headquartered in West Trenton, New Jersey. For nearly 70 years, we have specialized in the administration of multiemployer (Taft-Hartley) employee benefit plans, providing trusted administrative services to labor-management trust funds and their participants. Our success is built on three guiding principles: Integrity, Excellence in Service, and Cost Transparency. Our culture is driven by four core values: Service, Integrity, Accountability, and Collaboration. At I.E. Shaffer & Co., employees are empowered to make meaningful contributions, grow professionally, and build rewarding careers while supporting the administration of vital benefit programs that impact working families, retirees, and their beneficiaries. As a 100% employee-owned organization, we believe our people are our greatest asset and are committed to fostering a collaborative environment where expertise, initiative, and service are valued. I.E. Shaffer & Co. is an

Equal Opportunity Employer Pay:

$55,000.00 - $85,000.00 per year

Benefits:

401(k) 401(k) matching Dental insurance Health insurance Health savings account Paid time off

Work Location:

In person