Claims Analyst

The Business Analyst, Claims is responsible for supporting core claims processing operations for the health plan through workflow analysis, system support, and operational improvement initiatives. This role partners with Claims Operations and technical teams to troubleshoot processing issues, support system implementations and configuration changes, analyze claims data and trends, and identify opportunities to improve claims accuracy, turnaround times, and operational efficiency. Gathers and documents business requirements, supports testing and implementation activities, and helps ensure claims processes align with regulatory and organizational standards within a healthcare environment.

What We Provide

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities.

What You Will Do

• Maintains analysts' library of resources. Develops library of pertinent books and articles on information systems for the department.
• Develops an understanding of VNS Health Plans strategic business objectives and business unit operations, along a particular health plan value stream. Articulates business issues and designs data collection methodologies.
• Provides data collection and analytical support to team and monitors projects. Summarizes, creates, and distributes reports as needed.
• Participates in interdepartmental work groups in support of process improvement projects, as needed.
• Assists in the design and delivery of presentations on project status and outcomes to management.
• Monitors new and existing process designs to measure operational effectiveness.
• Provides financial impact analysis for all retro compensation grids as a result of amendments or new published state rates.
• Acts as a liaison between the claims department, providers and other internal departments.
• Manages workload and inventory according to departmental SLA.
• Identifies and creates global claim projects.
• Reviews claims disputes and pends within departmental SLA.
• Identifies and reports dispute trends.

• Audits processed claims for accurate payment.

• Participates in special projects and performs other duties as assigned.

Education:

• Bachelor's Degree in Business or related discipline or the equivalent work experience, required
• Master's Degree in Business Administration, Public Administration or related field, preferred

Work Experience:

• Two years' experience with claims in a healthcare setting required
• A year of experience with a managed care organization on business transformation required
• Two years' experience using FACETS, SQL scripts & queries, OBIEE, Power BI, Tableau & MicroStrategy reports & dashboards; project management & SDLC methodologies, with contracting and new business management across relational databases, using Oracle, SQL Server & DB2, managing stakeholder expectations and providing HIPAA-compliant guidance to business partners, vendors, and end-users, per industry standards for EDI protocols preferred
• Strong command of Microsoft Office Tools (Word, Excel, Visio, and PowerPoint) required
• Effective oral and written communication skills, consulting and analytical skills and ability to work with clients, IT management, staff, consultants and vendors required
• Ability to function autonomously, and collaborate with most senior level leaders across the agency required
• Demonstrated understanding of NYS, CMS and Medicare & Medicaid reimbursement guidelines. APG, APC, DRG required