Claims Systems Analyst

Healthplan Services Westerville , OH 43082

Posted 7 months ago

Position Summary:

The Business Systems Analyst will serve as the primary business analyst to assigned projects. They will work with senior management, client counterparts, and technical team members to identify, understand, and help quantify the business objectives for projects. They will assist in the definition of scope and the planning and initiation of these projects.

Core Responsibilities:

  • Working in partnership with multiple business and systems areas to achieve 100% accuracy of new business and planned change implementations

  • Perform business analyst functions on small to large projects

  • Demonstrate a thorough understanding of Health Benefits products

  • Provide clear description of problems-issues and present options for resolution

  • Develop test conditions and test cases for assigned projects

  • Execute testing for assigned deliverables

  • Update business documentation when required

  • Monitor plan dates and meet individual deliverables as well as support other team members to ensure project success

  • Appropriately escalate issues to management for support and/or guidance

  • Support cross functional teams

  • Contribute to team discussions, presenting ideas, and sharing knowledge to others

  • Collaborate on problem resolution, team decisions and project planning

  • Assist in determining resource requirements by estimating work efforts to project tasks

  • Collaborate on problem resolution, team decisions and project planning

  • Effectively gather and analyze data for trending

  • Serve as senior resource for team


  • 5+ years current health administration system experience

  • Strong analytical skills and the ability to communicate effectively

  • Effective independent presentation of data and findings

  • Expertise in using PC based tools

  • Ability to develop new team processes and procedures

  • Ability to review and analyze trending data

  • Strong oral and written communication skills; ability to convey ideas, problems, and issues to both business and system audiences

  • Strong organizational skills that allow the individual to handle multiple tasks while being extremely detailed oriented

  • Self motivated, self starter with ability to initiate projects, prioritize and meet deadlines

  • Solid knowledge of business/system functions

  • Proficient problem solving, interviewing, and analytical skills; ability to analyze and comprehend business/system processes

Preferred Experience:

  • Similar experience within a Large Health Plan or Claims Administrator (TPA)

  • Functional experience with any of the following areas: Claims Processing, Eligibility Maintenance, Utilization Management, Plan Benefits, Provider and Contract Maintenance

  • Technical experience with HIPAA transaction sets and analyzing health data

Education/Experience Requirements:

  • BA/BS degree in Business or equivalent experience
icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Senior Claims Representative

Meadowbrook Insurance Group, Inc.

Posted 7 days ago

VIEW JOBS 2/12/2020 12:00:00 AM 2020-05-12T00:00 The primary responsibility of this position is the management and resolution of complex commercial casualty claims with minimal supervision. Claims handled are among the most complex received and often present the highest and most severe potential exposure. Duties include but are not limited to: prompt and efficient investigation; analysis and verification of coverage; drafting of coverage position letters; litigation management; negotiation of settlements; attendance at meditations and/or trials as necessary; presenting analysis and recommendations to members of management; and establishing and managing proper reserves. While a legal background is desirable, it is not necessary. Significant experience managing commercial casualty claims is required. Territory is potentially all 50 states. Adjusters licenses are required for those states that have license requirements. ESSENTIAL FUNCTIONS: * Adjust a caseload of assigned files in accordance with AmeriTrust Group's policies and procedures. * Maintain an active diary on 100% of caseload files, with a current plan of action. * Adhere to assigned authority limits for reserving and payments (including settlements). * Exercise independent decision-making skills with minimal to moderate supervision and direction on claims assigned, using knowledge of local codes, laws, standards and case-law. * Verify coverage, investigate the loss by gathering all pertinent information, evaluate the claim, set reserves, negotiate settlements or deny payments where no overage, liability or compensability exists. * Record statements, obtain documentation such as police reports, medical reports, appraisals, estimates, photographs, etc. to process claims in accordance with Company standards. * Evaluate loss, assess reserve and settlements value where applicable and settle cases with claimants, insureds and attorneys autonomously. * Decide on denial of coverage, liability or compensability. * Assure all litigation cases are handled effectively and cost efficiently until legal settlement has been reached or judgment has been awarded, including decisions to award appeals, as assigned by Branch Management. * Identify and thoroughly investigate all possible recovery and subrogation opportunities revealed in the claims handled. * Return all telephone calls within one (1) business day, when possible. All messages from customers and agents are to be returned by the end of the same business day in which the call was received. Reports all service complaints to Claims Supervisor or Claims Manager immediately upon receipt. * Maintain personal compliance with all continuing education requirements as mandated by statute or by office policy. * Understand coverage issues with good knowledge of exclusions, endorsements on standard ISO forms. * Provide training and mentoring to other claims personnel upon management request. * Must adhere to the company code of ethics. * Professional and timely communication with all internal and external vendors. * Performs related duties as assigned. * Ability to interact with others in a professional manner. KNOWLEDGE, SKILLS AND ABILITIES REQUIRED TO PERFORM ESSENTIAL FUNCTIONS: * Bachelor's degree (B.A.) from a four-year university or college. * At least 5 years of experience commercial casualty claims. * Successful completion of one or more of the following educational programs through the Insurance Institute of America or the Professional Insurance Agents is preferred but not required: Chartered Property Casualty Underwriter (CPCU), Program in General Insurance, Associate in Claims (AIC), Senior Claim Law Associate (SCLA), etc. * Valid state adjusting license for the states of Arizona, Connecticut, Delaware, Florida, Kentucky, Louisiana, North Carolina, New Hampshire, New Mexico, New York, Oklahoma, Rhode Island, South Carolina, West Virginia Wyoming, Minnesota, and Vermont. * Ability to prioritize technically daily workflow. * Excellent written and oral communication skills. * Detail orientated with excellent organizational and planning skills. * Ability to work independently and with initiative is essential. * Experience negotiating settlements both telephonically and in person with attorneys, mediators, judges, or other carrier personnel. * Thorough knowledge of claim procedures, policies, terminology, etc. * Working knowledge of civil procedure, petitions, complaints, Department of Insurance operations audits. * Demonstrate strong problem-solving and analytical ability. * Working knowledge of civil procedure, petitions, complaints, Department of Insurance operations audits. * Spanish bilingual desirable or other languages. * Ability to travel as necessary. * Handle files in good faith as defined by statute, case-law and Corporate standards. * Computer proficient with Microsoft Office programs. * Sit, stand, walk/ambulatory. * Ability to lift 10 pounds. Meadowbrook Insurance Group, Inc. Westerville OH

Claims Systems Analyst

Healthplan Services