CLAIMS REVIEW ANALYST

Preferred Qualifications:

Proficiency in Microsoft Office applications, particularly Excel, including data entry, spreadsheet management, and reporting.

Experience maintaining accurate records, organizing documentation, and managing multiple administrative tasks while maintaining attention to detail.

Experience working with database systems, business management software, or electronic recordkeeping systems, including entering, updating, and verifying information.

Experience in the insurance industry, with a strong emphasis on claims management processes and workflows.

Proficient in collaborating and managing workflows within Microsoft Teams and SharePoint

Exceptional organizational skills, with demonstrated experience managing both digital and physical filing systems.

Ability to oversee and optimize staff scheduling and resource allocation.

Position Information

Job Series: Program Operations - Claims Review

Classification: Claims Review Analyst

Class Code: PCR01P

Pay Grade: SGS05

Salary Range: $47,397 - $70,148

Job Summary

The Claims Review Analyst is responsible for evaluating, analyzing, and processing insurance claims to ensure compliance with agency policies, industry regulations, and legal standards. This role involves verifying claim documentation, identifying discrepancies, assessing the validity of claims, and recommending approval or denial based on established criteria. The Claims Review Analyst may specialize in various sectors, including health insurance, property insurance, or workers compensation. They are key contributors to minimizing risk, preventing fraud, and delivering an efficient claims process to ensure customer satisfaction and operational integrity.

Primary Responsibilities

Review and analyze insurance claims for accuracy, completeness, and compliance with pre-determined policy terms. Identify and investigate discrepancies, missing information, or potential fraud. Collaborate with internal personnel, such as underwriting and legal teams, for complex claim assessments. Maintain detailed documentation of claim decisions and actions taken. Communicate claim outcomes and explanations to relevant organizations and individuals (e.g., policyholders or healthcare providers). Stay updated on industry regulations and trends to ensure adherence to best practices. Contribute to process improvement initiatives to enhance claim review efficiency.

Knowledge and Skills

Proficiency in data analysis, strong attention to detail, excellent communication, critical thinking, and knowledge of claims management software. Knowledge of local, state, and federal insurance regulations.

Minimum Qualifications

Bachelor's degree in a relevant field such as business, finance, healthcare administration, or insurance studies.

Satisfaction of the minimum qualifications, including years of experience and service, does not entitle employees to automatic progression within the job series. Promotion to the next classification level is at the discretion of the department and the Office of Personnel Management, taking into consideration the employee's demonstrated skills, competencies, performance, workload responsibilities, and organizational needs.

Licensure/Certifications

N/A OTHER JOB RELATED EDUCATION AND/OR EXPERIENCE MAY BE SUBSTITUTED FOR ALL OR PART OF THESE BASIC REQUIREMENTS, EXCEPT FOR CERTIFICATION OR LICENSURE REQUIREMENTS, UPON APPROVAL OF THE QUALIFICATIONS REVIEW COMMITTEE.