Remote Senior Claims Analyst

Job Title Senior Claims Analyst Status: Non-Exempt Why This Role Is Important: In the TPA world, precision, compliance, and cost control are everything. As a Senior Claims Analyst, you’re not just processing claims—you’re applying plan documents, regulatory standards, and sound judgment to every line item. You will play a vital role in protecting plan assets and ensuring members and providers are treated fairly. Our clients depend on us for accuracy, integrity, and accountability, and that starts with you. Essential Functions: Claims Processing, Review and Quality Assurance Process complex medical in accordance with plan documents, including PPO, HDHP, self-funded, and reference-based pricing plans. Interpret and apply Summary Plan Descriptions (SPDs) and employer-specific plan designs. Ensure claims are adjudicated according to plan eligibility, network discounts, medical necessity, COB, and applicable exclusions or limitations. Review provider billing for inappropriate billing practices. Apply Usual, Customary