Company Details


The Claims Data Analyst will be responsible for reviewing claims processed by the outside vendor including resolving provider appeals/disputes. Performs root cause analysis for all provider projects to identify areas for provider education and/or system (re)configuration. Initiates and follows through with resolution of all pended claims, (re)pricing, returned or refund checks and the development of provider and facility compensation grids. Provides feedback or suggestions to enhance current processes and/or systems.


  • Reviews, investigates, and submits claims to be adjudicated to outsource vendor. Reviews claims for medical and non-medical services that involve the application of contractual provisions in accordance with provider contracts and authorizations
  • Compiles claim reports for adjustments resulting from external providers, vendors, and internal inquiries in a timely manner
  • Investigates suspense conditions to determine if the system or procedural changes would enhance claim workflow
  • Communicates and follows up with a variety of internal and external sources including but not limited to providers, members, attorneys, regulatory agencies, and other carriers on any claim related matters
  • Analyzes patient and medical information to identify COB, Worker’s Compensation, No-Fault, and Subrogation conditions
  • Assigns appropriate ICD10-CD, HCPCS, and CPT4 codes as well as other codes necessary to process claims based on claim information submitted
  • Validates DRG grouping and (re)pricing outcomes presented by the claims processing vendor
  • Attends JOC meetings with providers as appropriate to assist in communicating proper billing procedures and to explain company coverage guidelines
  • Assists TPA with provider compensation configuration by creating and testing compensation grids used for reimbursement and claims processing
  • Ensures that refund checks are logged and processed enabling expedited credit of monies returned
  • Analyzes check return/refunds volumes and trends to determine root causes. Proposes workflow changes to correct and enhance claim processes to prevent returned checks/refunds
  • Generates routine daily, monthly and quarterly reports used for managing process timeframes and vendor productivity, ensuring compliance with all regulatory requirements and contractual vendor SLAs
  • Participates in special projects and performs other duties, as assigned


Education: Associate degree or the equivalent combination of education and experience required.


  • Minimum of two years of claims processing experience required.
  • Preferably working in a TPA, HMO, or managed care environment.
  • Knowledge of Medicare claims processing rules and coding experience with DRG, ICD10, and CPT4 is required.
  • Hospital claims experience required.
  • Proficient PC skills, including Microsoft Windows required.
  • Knowledge of HIPAA guidelines required.
  • Excellent communication and analytical skills are also required.
  • Work Schedule: MONDAY TO FRIDAY 9AM TO 5PM

Job Type: Full-time

Pay: From $58,000.00 per year


  • 401(k)
  • 401(k) matching
  • Dental insurance
  • Flexible spending account
  • Health insurance
  • Health savings account
  • Life insurance
  • Retirement plan
  • Vision insurance

Physical Setting:

  • Office


  • 8 hour shift
  • Monday to Friday

Ability to commute/relocate:

  • Bronx, NY 10461: Reliably commute or planning to relocate before starting work (Preferred)

Application Question(s):

  • Are you fully vaccinated for COVID19?
  • Is the Bronx commutable for you?
  • What is your desired salary?

Work Location: One location

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