Senior Claims Editing Analyst

Job Summary

Interpreting healthcare reimbursement policies, the full-time Senior Claims Editing Analyst will translate complex regulations into automated claims editing logic, ensuring payment accuracy while working remotely.

Key responsibilities

• Interpret and apply CMS, Medicare, Medicaid, and other payer policies to develop accurate claims editing logic
• Own the creation of high-quality edit specifications and conduct claims validation to ensure compliance and accuracy
• Collaborate with cross-functional teams to implement and document edit logic and policy interpretations effectively

Required qualifications

• 4+ years of experience in authoring claims editing content with vendors or payers
• Deep expertise in CMS policies, NCCI edits, and correct coding methodologies
• Strong understanding of claims processing workflows (CMS-1500, UB-04)
• SQL skills for claims analysis or edit opportunity identification (preferred)
• Clinical background (RN, BSN, PharmD, MD, or equivalent) is a plus