Description We are looking for a Medical Claims Analyst to support a commercial health plan review and audit initiative. The analyst will help evaluate medical claims for accuracy, compliance, and audit readiness while partnering with internal stakeholders to address issues and support timely resolution.

Responsibilities:

• Examine commercial medical claims to confirm correct processing, payment accuracy, and adherence to applicable audit standards.
• Investigate claim records specifically surrounding the No Surprises Act (NSA) and supporting documentation to uncover variances, exceptions, and items that require follow-up or correction.
• Validate claim details during audit-related reviews and maintain organized documentation to support findings and recommendations.
• Work closely with operational and compliance teams to resolve claim discrepancies and promote alignment with regulatory obligations.
• Assess denied, rejected, or adjusted claims to identify patterns, root causes, and opportunities for process improvement.
• Review claims across multiple jurisdictions and plan structures to ensure consistent interpretation of commercial health plan requirements.
• Use healthcare claims data and related systems to track issues, document outcomes, and support reporting on audit activities. Requirements
• Prior experience handling healthcare or medical claims in a payer, health plan, or related environment.
• Background in claims auditing, investigation, or examiner-level review work.
• Working knowledge of commercial insurance claims and medical billing practices.
• Understanding of claim denials, rejected claims, and common causes of processing inaccuracies.
• Familiarity with multi-state claims review and applicable compliance considerations.
• Knowledge of the No Surprises Act
• Strong analytical skills with the ability to interpret claim data, identify discrepancies, and document findings clearly.

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