Job Title: Claims Analyst (Third Party Administrator)

Job Location: Remote

Department: Operations

Reports To: Claims Manager

We are seeking a talented and detail-oriented Claims Analyst to join a rapidly growing Third Party Administrator (TPA) supporting proprietary employer benefits programs. This role is responsible for reviewing and analyzing insurance claims to ensure accurate processing in accordance with plan documents, internal policies, and industry regulations.

The Claims Analyst will evaluate claims submitted through the system and make informed decisions regarding approval, denial, or adjustment. The ideal candidate has a strong understanding of healthcare benefits, claims system operations, and regulatory requirements, and is comfortable exercising judgment in a structured claims environment.

• Review and Assess Claims: Analyze insurance claims submitted by providers and facilities to ensure compliance with policy criteria. Review claim details and supporting documentation, including medical records, accident letters, and other relevant materials as applicable.
• Evaluate Coverage: Determine applicable coverage based on policy terms and conditions.
• Verify Information: Confirm the accuracy and authenticity of submitted documentation, including identifying discrepancies or potential fraud.
• Approve, Deny, or Adjust Claims: Make determination decisions based on evidence reviewed, including COB information and supporting documentation.
• Special Projects: Assist with ad hoc tasks or assignments as directed by the management team.
• Ensure Compliance: Adhere to insurance regulations and company policies to ensure claims are processed legally, ethically, and accurately.

• Education: High School diploma required.
• Experience: Previous experience in claims processing, customer service, or a related field—preferably within healthcare, insurance, or a third-party administrator (TPA) environment.
• Attention to Detail: Strong ability to accurately assess and process claims.
• Analytical Skills: Ability to analyze complex information and make sound, well-documented decisions.
• Communication Skills: Strong written and verbal communication skills for interaction with providers, members, and internal teams.
• Knowledge of Insurance Policies: Understanding of insurance terminology, policies, and regulations.
• Problem-Solving Skills: Ability to identify issues, think critically, and resolve problems efficiently.
• Technical Skills: Proficiency with claims management systems and basic office software (e.g., Microsoft Office).