Senior Claims Process Analyst

Job Summary

Working remotely, the full-time Senior Claims Process Analyst will manage the investigation and resolution of Dual Eligible Special Needs Plan (DSNP) Maximum Out-of-Pocket (MOOP) issues, conducting root cause analysis and collaborating with various teams to enhance claims processing and member experience.

Key responsibilities:

• Review and resolve DSNP MOOP overages and accumulator discrepancies
• Conduct detailed root cause analysis and identify trends across claims and eligibility records
• Collaborate with internal and external partners to implement process improvements and ensure compliance

Required qualifications:

• High School Diploma / GED or equivalent work experience
• 1+ years of claims adjustment experience within CSP Facets
• Experience researching and resolving complex claims and accumulator issues
• Ability to perform root cause analysis and identify trends
• Experience in healthcare operations, claims processing, or government healthcare programs