Professional Claims Analyst

This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Professional Claims Analyst in United States.

This role sits at the intersection of healthcare claims analysis, operational support, and system optimization, offering the opportunity to directly influence the accuracy and efficiency of complex claims processing workflows. You will be responsible for investigating paid and denied claims, identifying discrepancies, and analyzing system behaviors within pharmacy claims environments. Working in a fast-paced and highly regulated setting, you will collaborate closely with claims leadership, technical teams, and external stakeholders to resolve issues and improve overall claims performance. The position involves both analytical depth and operational execution, requiring strong attention to detail and a solid understanding of claims adjudication systems. You will also contribute to testing activities, reporting, and continuous improvement initiatives that enhance system reliability and financial accuracy. This is a highly impactful role for professionals who want to strengthen healthcare operations while supporting better outcomes for members and providers.

Accountabilities:

• Support daily claims operations by analyzing paid and denied claims, identifying discrepancies, and investigating system or pricing issues
• Assist the Claims Manager with testing activities, including POS test case creation, smoke testing, deployment validation, and post-implementation monitoring
• Research and resolve pharmacy claims inquiries by communicating with pharmacies, members, and insurers to gather required information
• Contribute to system improvement by identifying trends, evaluating claims data, and supporting edit changes or new configuration requirements
• Assist in developing and maintaining training materials, workflows, and documentation to ensure alignment with business needs
• Support reporting, audits, and documentation requests while ensuring accuracy and compliance with established standards
• Collaborate with cross-functional teams to improve claims adjudication processes and operational efficiency
• Participate in special projects, continuous improvement initiatives, and enhancements to claims systems and processes

Requirements:

• Bachelor’s degree in business, insurance, healthcare administration, or related field, or equivalent combination of education and experience
• Minimum of 3 years of experience in claims processing, preferably within pharmacy or healthcare claims environments
• Strong understanding of claims adjudication systems, documentation standards, and administrative or regulatory guidelines
• Experience with pharmacy claims configuration processes and familiarity with Medicaid environments is a plus
• Strong analytical, investigative, and problem-solving skills with the ability to identify trends and inconsistencies
• Excellent attention to detail, time management, and organizational abilities in a fast-paced environment
• Proficiency with Microsoft Office tools, particularly Excel, and general computer literacy
• Strong written and verbal communication skills with the ability to work independently and collaboratively
• Ability to manage multiple priorities and meet tight deadlines while maintaining accuracy and quality
• Nationally Certified Pharmacy Technician certification preferred

Benefits:

• Competitive annual salary ranging from $47,000 to $67,200 USD, depending on experience, skills, and location
• Fully remote work environment within the United States
• Comprehensive healthcare coverage, including medical, dental, and vision plans
• 401(k) retirement plan with employer contributions
• Flexible paid time off policy supporting work-life balance
• Educational assistance and continuous learning opportunities
• Access to leadership development and technical training programs
• Opportunity to work on impactful healthcare systems improving claims accuracy and efficiency
• Inclusive, collaborative, and mission-driven work culture focused on healthcare improvement
• Eligibility for additional employee programs and benefits based on company guidelines

How Jobgether works: We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team. We appreciate your interest and wish you the best! Why Apply Through Jobgether? Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time. #LI-CL1