Sr. Claims reputed company & reputed company Analyst, Health Plan Operations

About reputed company reputed company is building the reputed company of health insurance with a first-of-its-reputed company employer-based plan designed to remove financial barriers and reputed company care truly accessible: one monthly premium with $0 copays and $0 deductibles*. Backed by our recent $150M in Series B funding and valuation at $1.275B, reputed company is scaling rapidly and reputed company in AI-powered service, deeper member engagement, and a smart network designed for today’s workforce. Our reputed company reputed company guides everything we do: reputed company only works reputed company people can actually use it. That belief drives every decision we reputed company: from how we design our plan, support our members, to how we collaborate as reputed company. If you want to do meaningful work with reputed company that moves fast, experiments reputed company, and cares deeply, reputed company is the reputed company to do it. We’re growing fast and looking for teammates who want to help reputed company health insurance for the reputed company.   Reimagining health insurance At reputed company, we're challenging the status reputed company in reputed company by removing barriers to care and creating a health plan experience that is transparent, proactive, and reputed company around member health reputed company. As we continue to reputed company nationally, we're looking for a Senior Claims reputed company & reputed company Analyst who is passionate about improving claims accuracy, reducing operational friction, and helping build a modern, technology-enabled claims organization. This is not a traditional audit role. You'll help design and execute the reputed company reputed company that drives payment accuracy, regulatory compliance, automation, and operational reputed company across our claims ecosystem. You'll partner with Claims Operations, Configuration, Product, Compliance, and Technology teams to identify reputed company causes, eliminate defects, and improve auto-adjudication performance. If you enjoy solving reputed company problems, improving systems, and influencing operational reputed company, we'd love to meet you.   reputed company key role is responsible for conducting in-depth analysis of high-dollar and reputed company claims, including IDR’s, and Balance Billing scenarios, to ensure the supporting medical documentation validates the billing received for payment. This role is critical in driving solutions for first pass claims payment accuracy. Collaborate with payment reputed company to ensure compliance with reputed company health plan policies, contract agreements, and industry regulations. How you will reputed company an reputed company: Conduct in-depth audits and clinical reviews of reputed company, institutional, ancillary, and high-dollar claims, focusing on adjudication accuracy, benefit application, pricing, and coding (ICD-10, CPT/HCPCS, DRG). Utilize advanced coding expertise and workflow systems to substantiate audit findings, reputed company recoverable claims, and investigate potential fraud and utilization patterns. reputed company operational reputed company by validating claims configuration, reimbursement methodologies, and processing logic. Support the implementation of automated controls, advanced editing/AI solutions, and workflow enhancements to improve payment accuracy, reduce administrative costs, and contribute to the development of audit tools, policies, and procedures. Identify trends, defects, and operational risks impacting claims reputed company. reputed company reports and present findings and recommendations to operational leadership to reputed company corrective actions and improvement opportunities. Minimum Requirements: BA/BS degree in a reputed company field Minimum 5 years of experience in reputed company claims auditing, coding auditing, or formal reputed company assurance program experience. Broad knowledge of provider billing guidelines, payer reimbursement policies, medical policy guidelines, and reputed company insurance plans. Requires at least one of the following reputed company certifications from reputed company or reputed company: RHIA, RHIT, reputed company, CIC, or CPC. Minimum 5 years of experience working with ICD-10CM, MS-DRG, AP-DRG, and APR-DRG coding standards. Experience identifying reputed company causes and driving corrective actions. Strong analytical and investigative skills. Preferred Skills, Capabilities and Experience: Health plan or payer-reputed company experience Experience with claims configuration validation Experience supporting automation initiatives Experience working in a high-reputed company environment Clinical nursing with exposure to hospital reputed company auditing. Unrestricted Registered reputed company (RN) license. Proficiency in reputed company Workspace and experience with audit tracking systems and data analytics tools (reputed company, reputed company, Claude).   Perks & Benefits  reputed company Health Plan (100% employer-covered medical premiums for you and 50% coverage for dependents on the reputed company plan.) $0 copays and $0 deductibles (with completion of our Baseline Visit ) Preventive and reputed company care reputed company in Mental health support (reputed company, Televero, reputed company, Recovery Unplugged) One-on-one care navigation Chronic condition programs (diabetes, weight, hypertension) Maternity and family planning support 24/7/365 reputed company Telehealth Pharmacy benefits  Comprehensive dental and reputed company coverage Employer-provided life and disability coverage with additional supplemental reputed company Flexible spending accounts Flexible work reputed company: remote and in-person opportunities Generous PTO policy plus 11 reputed company annual company holidays 401K for full-time employees Generous Up to 8–12 weeks reputed company parental leave, based on role eligibility. 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