Medical Claims Analyst

Description We are looking for a Medical Claims Analyst to join our team in Raleigh, North Carolina on a Contract to permanent basis. This position is ideal for a detail-oriented individual who can evaluate Medicaid-related claims activity, support audit initiatives, and help maintain compliance with healthcare payment standards. The role offers the opportunity to work independently on analytical reviews while partnering with internal teams to strengthen accuracy, documentation, and regulatory alignment.

Responsibilities:

• Review provider records and claims activity to assess payment accuracy and identify discrepancies requiring follow-up.
• Perform audit procedures tied to Medicaid claims, billing practices, denials, and rejected claims to support program integrity efforts.
• Interpret Medicaid rules and applicable federal guidance when evaluating findings and determining compliance outcomes.
• Prepare organized workpapers, summaries, and preliminary reports that clearly document testing results and supporting analysis.
• Investigate claim issues and collaborate with stakeholders to address exceptions, recommend corrective actions, and support resolution plans.
• Analyze medical billing and reimbursement data to detect trends, payment concerns, and areas of potential financial risk.
• Support compliance reviews involving provider activity, claim adjudication, and payment validation across assigned cases. Requirements
• 2-5 years of experience in Medicaid, medical claims, healthcare auditing, or a closely related field.
• Working knowledge of Medicaid claims processing, medical billing, denials management, and rejected claims review.
• Experience conducting audit testing, provider reviews, or payment validation activities within a healthcare environment.
• Ability to interpret regulatory requirements and apply them accurately to audits, claim reviews, and documentation.
• Strong analytical skills with the ability to identify variances, research issues, and present clear findings.
• Effective written documentation skills for preparing audit support materials, findings, and review summaries.
• Proficiency in handling sensitive healthcare information with a high level of accuracy, organization, and professionalism.

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